May I share my time with Senator Honan?
Adjournment Matter. - Breast Screening Programme.
Is that agreed? Agreed.
Since I was a medical student the incidence of breast cancer has increased two-fold. This is a real increase, not simply an increase due to better diagnosis or because women are living longer. However statistics are being bandied about at present which are alarming rather than alterting women. The increase in the incidence of breast cancer is extremely serious and is naturally a great worry to all women, the medical profession and women doctors like myself, who take a particular interest in women's health care.
We need to introduce a logical order into how we look at the problem. It is being said that one woman in 11 gets breast cancer. This leads women to think that one women of every 11 women of 50 years of age has breast cancer, but this is not so. The incidence increases with age and such factors are not explained to people.
Various women's organisations, including the Council for the Status of Women and the Irish Countrywomen's Association, have campaigned recently for breast screening. They have contacted all women Members of the Oireachtas and those involved in health about establishing breast screening in Ireland. There was a useful debate on the subject in the Dáil on Wednesday.
Even if the Minister for Health had millions of pounds available to him to set up a breast screening programme he would be unable to do so. Breast screening is not a matter of choosing women aged 50 or over at random and asking to screen them. The programme must be set up with a tight Protocol and must be properly ordered, otherwise the exercise will be pointless.
There is a debate in medical circles at present about the value of mammography in breast screening. Having read the literature carefully I feel it is of value in women over 50 if combined with a good clinical examination — the latter is important. Breast tissue is too dense in women under 50 for mammography to be of value. While it is valuable in the diagnosis of already palpable breast lumps in women under 50, the same has not been found true of screening.
Breast screening must be done in a validated centre and a clinical examination is important. I say this despite the fact that the late Dr. Maureen Roberts, a friend of mine, and Professor Patrick Forrest set up breast screening in Great Britain. She died at 56 years of age from breast cancer and she left an emotional article, which was published posthumously in the British Medical Journal, which she queried the value of breast screening. Having read the literature I believe breast screening is worthwhile.
I would like the Minister for Health, Deputy Howlin, to set up breast screening for women over 50 years of age by a certain date and to establish a population register. No screening can be set up until this is in place. I was an observer at the Oireachtas Joint Committee on Women's Affairs some months ago and one of our most distinguished epidemiologists also said this. Recently the professor in charge of the breast clinic at St. Vincent's Hospital agreed with her. I refer to the European Journal of Cancer Prevention which states:
An essential prerequisite for a population based programme is a register which enumerates each member of the target population, since accurate denominator information is essential for any conclusions to be drawn. A particular problem in setting up a population based project in Ireland was the absence of any population register. The register constructed for this programme, [the Eccles Street breast screening programme, which is one of 12 pilot studies being done throughout the EU], while successful in identifying 84 per cent of the target population, is not perfect. For example, it has not been possible, from within programme resources, to update the register continuously, correcting for movement of people in and out of the target population. Furthermore, restrictions placed on the use of personal data may preclude future access to demographic information from sources available to this programme. These are serious considerations in any decision to extend the programme nationally.
Great Britain and the Netherlands are the only countries in Europe carrying out breast screening at present and both have population registers. We have problems establishing one here, but that does not mean we should not address this matter. The names, addresses and ages of approximately 70 per cent of the population are available from the General Medical Service registers which are held by the different health boards. However, they are not all computerised and those which are do not have systems which marry satisfactorily or which marry with the computer in the Department of Health. However, this involves computer policy and it is not my business.
Those outside the GMS or in private health insurance schemes, such as the Voluntary Health Insurance, also experienced problems. The VHI had to write to all the women on its books in the birth cohort, which was to be screened, to ask permission to give their names to the Eccles Street breast screening programme. This was a large task for the two areas involved, North Dublin and Cavan-Monaghan, but it had to be done to avoid prosecution under the data protection legislation. Other private insurance schemes would also need to be contacted.
One must decide on the cohort when setting up a breast screening programme. For example, it could be women who are 50 years of age. As soon as a woman reaches 50, a card could be sent inviting her to attend for screening, This must be set up before breast screening can take place. One could then decide how often she needs to come back, perhaps every two or three years. Women over the age of 65 are reluctant to go for screening. Perhaps this is due to a false sense of security.
The Eccles Street breast screening programme has an 84 per cent take-up and it has been applauded by the experts from the European Commission on Cancer who visited this country. They praised the Irish survey and said it was one of the best of the 12 being undertaken. It had strong clinical leadership, good epidemiology, a high level of technical expertise and so on. However, we must be careful not to set up too many facilities for mammography. At present, there are 17 facilities throughout the country.
I recently visited the women's research unit of the National Institute of Health in Washington DC and I spoke to the woman in charge of research in the breast screening area. She said that breast screening facilities must be legally validated to show they have reached a certain standard. I am not suggesting that facilities here are not up to standard, but we must consider this aspect.
It is no good asking people to attend for screening in centres which may only do three or four sessions a week. One must have a substantial throughput so that radiographers and radiologists will be able to increase their expertise and abilities to read the sensitive X-rays. There are four or five doctors in the House and I am sure if someone came in with an X-ray of a broken leg and asked us to look at it, we would be able to confirm that the leg was broken. The same would be true of a chest X-ray. However, if someone asked us to look at a mammogram we would tell them to take it away because it is a specialised area. One must have a certain throughput in order to increase one's clinical skills. Some experts say 2,000 mammograms a year going through a unit are needed to do this.
While focusing on breast screening, I must be careful that women do not lose sight of what may be the most important aspect of the treatment of breast disease, early diagnosis. As soon as they find a lump on their breast they should go to the doctor, who is well trained to refer them to a specialist. I talked to a young graduate in John Hopkins Hospital in Baltimore and I was told they rely on early diagnosis. We must be careful because women, including myself, deserve good health. We cannot ask for mammography and breast screening if they might be counterproductive.
When I get an opportunity to talk to the Minister for Health about this matter, I will tell him that I do not want breast screening only when he sets up the screening project. I want women to have a full health examination if necessary. If women will not go to their GPs, this is the best way to approach this issue. Some women think that the family's health is more important than their own. This is a serious problem and it is being addressed in a haphazard way. I ask the Minister to give us some guidance and direction by establishing a population register.
I thank Senator Henry for allowing me to share her time. I support this motion because it is important. This issue was discussed in the other House during the week.
The ICA and the Council for the Status of Women have lobbied us to encourage the Minister to set up a screening programme throughout the country. Many women believe that if a mammography service was established in every county all women with breast cancer would be diagnosed at an early stage. When women Members of the Oireachtas met Professor Given of the breast cancer unit in the University Hospital Galway, I was shocked when he informed us that mammography for pre-menopausal women under 50 was a waste of time and that breast examination was most important. Women need to be educated on the importance of this examination.
In addition to setting up a breast screening programme throughout the country, I suggest that the Minister also set up a programme whereby women could go to their GPs for a breast examination free of charge twice a year. As Senator Henry said, early detection is important. In the new health strategy, Shaping a Healthier Future, the Minister mentioned prevention and this is important. In the last three years 2,000 women have died from breast cancer. A breast screening programme would be of great benefit to the country.
I support Senator Henry's request to establish a population register because we cannot proceed with the nationwide screening programme until this is done.
I am standing in for the Minister for Health, Deputy Howlin.
I thank Senator Henry and Senator Honan for raising this important matter. We all know of circumstances where women have died because of the late detection of breast cancer. It is important that the best possible measures are in place to avoid that. Senator Honan said 2,000 women have died over the past three years, approximately 650 each year.
The causes of breast cancer remain to be clearly established and emphasis is therefore placed on early detection at the pre-invasive stage through mammography and consequent early treatment. At present, mammography is used largely as a diagnostic tool for symptomatic or worried women on referral by their general practitioner, consultant or through the local breast clinic. There are now diagnostic mammography units at 17 hospital throughout the country and expertise has been growing in all aspects of the early detection of breast cancer and its treatment.
Mammography screening involves the carrying out of mammography on a mass population basis to detect breast cancer in non-symptomatic women. Mammography screening programmes tend to be directed at women aged between 50 and 64 years. There is a general agreement that mammography screening programmes are not effective in reducing mortality in younger women.
It may be helpful to briefly outline some of the general principles considered necessary to underpin a successful mass screening programme. One of these is that the natural history of the disease should be well understood. Another is that there should be a suitable screening test and one which is acceptable to the population to be screened. Another essential factor in the success of such a screening programme is a high and consistent participation rate among the population to be screened. The absence of a national population register on a named basis makes the implementation of a national screening programme all the more difficult. The establishment of such a register would not, however, be the primary responsibility of the Minister for Health but the difficulties to which its absence gives rise in the context of any health screening programme is something which he will be discussing with the Government shortly.
The United Kingdom and the Netherlands are the only two countries in the European Union which have organised national mammography screening programmes for women aged between 50 and 64 years. However, there is considerable debate and discussion internationally regarding the effectiveness of mammography screening programmes in reducing mortality from breast cancer. Before proceeding with a national screening programme for women aged 50 to 64 years, it is imperative that the benefits of mammography screening, in terms of achieving a reduction in mortality, are carefully and fully assessed.
For these reasons, the Department of Health is supporting a major mammography breast screening programme currently under way at the Mater Foundation. This programme, the Eccles Street breast screening programme, is one of a network of pilot schemes which are at present under way in seven countries within the European Union. The other countries are Belgium, France, Spain, Portugal, Greece and Italy. The Irish pilot programme covers a defined catchment area, North Dublin and Cavan-Monaghan, representing both urban and rural populations. All women in the catchment area between 50 and 64 years are eligible to attend. Screening is provided free of charge to women taking part in the programme. The objectives of the Eccles Street breast cancer screening Programme are as follows: to evaluate the impact of mammographic screening on mortality from breast cancer among Irish women; to document compliance with a breast screening programme in Irish women and to compare the specificity, sensitivity and predictive value of the mammography programme with that reported internationally.
The second round of screening is expected to be concluded by the end of 1994. The Eccles Street breast screening programme is the first study of its kind undertaken in this country. As indicated in the new health strategy, Shaping a Healthier Future, national policy to be followed in this area will be guided and influenced by the experience gained through the pilot programme.
I undertake to pass on a number of the details raised today. They will help the Minister for Health and the Government in furthering this matter by establishing the register requested as soon as possible if it is feasible. It will also help alleviate some of the apprehensions women have in going for screening.
I thank the Minister for that clear statement. It is important that we stress that mammography for the diagnosis of a breast lump is not the same as screening asymptomatic women. I thank Senator Honan for her suggestion that women should be advised to go even once a year to their GP for breast examination.
Given that one always asks a Minister for money, I ask that the Eccles Street breast screening programme be given more money. I gather that at the end of this year it will have run out of its EU money. In view of the praise the programme received from the European Commission on Cancer, it would be sad if the work of this unit did not continue and, if necessary, expand.
The Seanad adjourned at 1.45 p.m. until 2.30 p.m. on Wednesday, 4 May 1994.