Seanad Éireann debate -
Tuesday, 29 May 2001

Vol. 166 No. 18

Women's Cancer Strategy: Statements.

Minister for Health and Children (Mr. Martin)

I am pleased to be given the opportunity today to brief the House on developments to date under the national cancer strategy and outline the areas of cancer services which have been particularly targeted under the strategy with regard to women's health and women's cancers.

The reorganisation of our cancer treatment services was an integral part of the 1994 health strategy, Shaping a Healthier Future, and targets were set for reducing the mortality from cancer in the under 65 year old age group by 15 % in the period 1994 to 2004. Health care services were to be focused on improvements in health status and quality of life and increased emphasis was to be placed on the provision of the most appropriate care for patients. Cancer was identified as one of the major sources of premature mortality in Ireland. The effect of cancer on health status in Ireland is striking. There was a clear need to address this and the national cancer strategy emerged as an evidence based initiative to enable high quality cancer services to be developed throughout the country. Included in the national cancer strategy was the commitment to develop screening programmes in the area of breast cancer and cervical cancer.

The two principal objectives of the national cancer strategy are; to take all measures possible to reduce rates of illness and death from cancer, in line with the targets established in Shaping a Healthier Future and ensure those who develop cancer receive the most effective care and treatment and that their quality of life is enhanced to the greatest extent possible.

There are specific objectives in relation to key elements of the cancer strategy concerning such areas as prevention of cancers for which a cause is known or suspected, access to equitable, effective, quality services throughout the country, improved quality of life for patients, appropriate multi-disciplinary treatment administered safely and in accordance with best practice guidelines, greater co-ordination of cancer treatment services from primary care to hospital care through to rehabilitation and palliative care, promotion of arrangements for appropriate research and education for those providing cancer services and a co-ordinated approach by all those involved in the care and treatment of patients with cancer to ensure all services are provided in a cost-effective manner.

There are specific objectives in relation to key elements of the cancer strategy concerning such areas as prevention of cancers for which a cause is known or suspected; access to equitable, effective, quality services throughout the country; improved quality of life for patients; appropriate multi-disciplinary treatment administered safely and in accordance with best practice guidelines; greater co-ordination of cancer treatment services from primary care to hospital care through to rehabilitation and palliative care; promotion of arrangements for appropriate research and education for those providing cancer services; and a co-ordinated approach by all those involved in the care and treatment of patients with cancer to ensure that all services are provided in a cost-effective manner.

A range of support structures were put in place to co-ordinate and take a lead role in the implementation of the national cancer strategy. The first National Cancer Forum, under the chairmanship of Professor James Fennelly, was established. The forum, a multi-disciplinary body, proved to be an extremely useful body and advised on many issues central to the successful implementation of the strategy. The term of office of the first forum expired last year and I subsequently appointed Professor Paul Redmond as chairman of the second National Cancer Forum. The forum is currently examining a number of issues of tremendous importance to the effective progression of the development of cancer services in this country. Areas such as protocols for the care and treatment of cancer patients, information requirements and audit and evaluation of our services are all important component parts of the appro priate future development of cancer services, and the forum, as the established expert advisory body, will report to me on these issues.

Regional directors of cancer services were appointed in each health board area to oversee and co-ordinate the development of cancer services in their respective areas in conjunction with the chief executive officers of the health boards. The regional directors are proving to be of great benefit in assisting in the development of appropriate future cancer services.

I am very pleased to report to the House today that there has been considerable and tangible progress to date under the national cancer strategy. The strategy has been progressed far beyond the original commitments made in the action plan for its implementation.

The implementation of the national cancer strategy was estimated to cost £25 million when it was launched. The sum allocated for the strategy in 1997 was £6 million. Since then the Government has invested £54 million in cancer prevention, treatment and care services, including £11 million last year and almost £19 million this year. All the commitments made in the action plan for the implementation of the strategy have been fully funded and are implemented or are in the course of implementation. The main implementation elements of the strategy included the areas of cancer prevention, early detection and screening, additional consultant appointments in key areas of cancer treatment and care and cancer research.

There have been a number of key consultant appointments since the commencement of implementation of the national cancer strategy. There have been 55 additional consultant appointments in the areas of medical oncology, haematology, histopathology, palliative care and specialist surgery. In addition, new consultant appointments have been approved in the specialty of radiation and clinical oncology at St. Luke's Hospital, Dublin.

Cancers occur as a result of the interplay between genetic and environmental factors. Risk of cancer depends on age, sex, genetic make-up and where and how people live. To some extent certain aspects of cancer risk are within our control. There is strong evidence that lifestyle and environmental factors play an important role in the development of cancer. The use of tobacco, the excessive consumption of alcohol and unhealthy diet contribute to increasing the risk of developing cancer. It is important that the public is made aware of the scope for preventing many cancers by making appropriate lifestyle changes. To this end, the health promotion unit of my Department supports an extensive range of initiatives that have an impact on the levels of knowledge and awareness of the risk factors associated with many cancers. These include mass media campaigns on anti-smoking, alcohol awareness and healthy eating. The unit also provides funding to the Irish Cancer Society in support of cancer prevention initiatives, including the yearly Europe Against Cancer campaign.

As more and more people are aware, the prevention and reduction of skin cancer can be achieved by a vigilant approach to sun exposure and artificial forms of UV radiation. Utilising sun protective clothing and creams as well as early detection can reduce deaths from skin cancer. Early detection of melanoma can be facilitated by consulting a physician if a mole changes shape, size or colour. People must be informed of the risk associated with sunburn. To this end the health promotion unit has put concise information on this subject into booklet form and made it widely available.

BreastCheck, the national breast screening programme, commenced in February 2000. Phase one of the programme covers the Eastern Regional Health Authority, the North Eastern Health Board and the Midland Health Board areas. Screening is being offered free of charge to all women in the target age group of 50 to 64 years on an area by area basis.

In the period January to March 2001 approximately 2,700 women per month were screened at the BreastCheck units and approximately 700 women per month were screened on the mobile unit. Less than 1% of those screened are admitted to hospital for further management.

The board of BreastCheck has reviewed progress to date and has informed me that it is pleased with the uptake of women in the areas screened so far, with uptake having virtually reached its target level of 70%, while meeting the quality parameters set and providing evidence of a significant level of screen detected cancers.

The successful roll-out of the programme is dependent on a number of factors, including the availability of appropriately trained staff. BreastCheck offers suitably skilled radiographers the opportunity of working in state-of-the-art facilities as well as an attractive employment package. The board has taken a number of initiatives to address the issue of the current shortage of suitably skilled radiographers, including an international advertising programme. BreastCheck, in conjunction with the School of Diagnostic Imaging at the Faculty of Medicine, UCD, has set up a post-graduate diploma in mammographic imaging, the first of its kind in Ireland. This joint initiative aims to increase levels of mammographic trained radiographers in Ireland and share the experiences of BreastCheck with other mammography services.

The board of BreastCheck plans to carry out a feasibility study nationally on the availability of skilled staff for the programme and this is expected to be complete in a number of months. It expects to make recommendations to me regarding the extension of the programme to the rest of the country later this year. Breast screening has a significant part to play in reducing morbidity and mortality from breast cancer. I am committed to the extension of BreastCheck to ensure that women throughout the country have the highest quality breast screening services available to them. This involves not only screening services, but also the availability of quality symptomatic services so that an equally high standard of hospital care is available for those who may require it following a screening detected cancer.

BreastCheck is providing an excellent, intensely quality assured service for screened women who believe that they are healthy and for the treatment of the women who, through screening, are discovered to have breast cancer. It is essential that this service is matched by an equally excellent service for those with symptomatic breast disease. As the plans for the commencement of BreastCheck progressed, it soon became apparent that the symptomatic breast cancer services in this country were not provided in the manner which would or should lead to the best outcomes for women. International experience tells us that women who are treated in a multi-disciplinary centre where all the relevant medical expertise is on one site and where there is a minimum number of patients with similar disease treated by the same team have a greater chance of long-term survival and have less of a chance of their disease recurring than those treated in smaller centres.

Having regard to these concerns, my predecessor, Deputy Cowen, requested the National Cancer Forum to review symptomatic breast disease services nationally. The forum established a sub-group to undertake this task. The report on the development of services for symptomatic breast disease was presented to me in April last year. I accepted the broad thrust of this report and established an advisory group to meet all the health boards to advise and assist in formulating regional plans for the implementation of the report.

Concerns were raised in many areas because of a perceived notion that certain smaller hospitals around the country would be downgraded if they did not maintain their mammography services. I stress to the House that this report was not about the downgrading or closure of any hospital. It is about the reorganisation and development of breast disease services in centres of excellence to ensure that every effort is made to reduce the number of women in this country who die from breast cancer every year. I have provided funding of over £4 million this year to enable a number of agencies to commence the development of at least seven centres of excellence for the treatment of symptomatic breast disease. Funding has been allocated to the Eastern Regional Health Authority, the Midland Health Board, the North Eastern Health Board, the South Eastern Health Board, the Southern Health Board and the Western Health Board.

The National Registry Board reports that between 1994 and 1997 cervical cancer accounted for an average of 74 deaths in Ireland each year, with cervical cancer being more common in older women. The report, Developing a Policy for Women's Health, states that while cervical screening is simple, quick and relatively inexpensive, not all women respond to requests to attend for screening. It has been found that women in the lower socio-economic groups may fail to do so and it is mainly among these groups that deaths from cervical cancer occur. Experts in the Europe Against Cancer programme recommend that women between the age of 25 and 60 years should have a cervical smear regularly and should participate in organised screening programmes where available.

With these considerations in mind, phase one of the national cervical screening programme commenced in the Mid-Western Health Board area in October 2000. Under the programme, in the region of 67,000 women aged from 25 to 60 years will be screened free of charge at minimum intervals of five years. The question of extending the programme to the rest of the country is under consideration by my Department in conjunction with the chief executive officers of the health boards and the expert advisory group on cervical screening.

As the House will gather, I am very well aware of the issues relating to women's cancers. The considerable investment under the national cancer strategy will undoubtedly enhance the quality of services available to women, provide further ease of access to these services by providing for the development of quality services on a regional basis and ensure that those who develop cancer receive the appropriate treatment administered safely in accordance with established best practice. I am committed to the further implementation of the national cancer strategy to ensure that women who develop cancer have available to them the best, safest and most effective treatment and so have the best opportunity for long-term survival.

Mrs. Jackman

I welcome the Minister to the House. I listened carefully to his contribution, and while I accept that the Minister is a compassionate man, I found his speech sterile in that it concerned funding and programmes but lacked feeling for the issue of cancer among women. When women hear they have cancer they initially believe that it is their death knell, although many cancers are treatable if caught early. If women are screened they have a high incidence of survival and can lead healthy and happy lives. However, cancer remains a frightening scenario for women. This debate is painful for me due to the many meetings I have attended recently about cancer. Many women would not speak openly up to now but there is a turn in the tide regarding discussion of the subject. Women are now looking for what has been promised for some time.

I was deeply involved with the issue during the time of Deputy Noonan's plan for women's health for the years 1997 to 1999. I have served on health boards and was conscious of what was happening in the area. Deputy Noonan, as Minister for Health and Children, set about a consultation process. That was a major reason women came forward. Deputy Noonan worked on policy with the National Women's Council and there was accountability on both sides. Both contributed their plans for women's health to the debate, and there was an aspiration to bring the health of Irish women up to EU levels. This was in relation to several diseases including heart disease, although we are only looking at cancer today. This process of consultation is extremely important. The Minister must begin such consultation regarding the various types of cancer. He should create increased awareness among women that help is available.

The Oireachtas Joint Committee on Health and Children has debated the issue of smoking many times, whether it was in relation to proposals from Deputy Shatter or the current Government. However, there is little reduction in the incidence of smoking, and I speak as an observer of young people. It does not matter if cigarettes rise to an abnormal price; young people are still smoking and contributing seriously to ill health in the future. Irreparable damage is done even during the teenage years. There has been an impression that if a person gives up smoking, things will be fine. However, teenage and younger lungs are so tender that the damage done is very serious, as Senator Fitzpatrick can attest. Nothing seems to get through to young people, despite the most horrific advertisements. I despair of the high incidence of smoking, but the young do not think in terms of their future.

Cancer accounts for approximately 20% of deaths among women in Ireland, according to the Noonan document on women's health. That is a shocking statistic. It is interesting that the scope for reducing mortality among women is greatest for cancer of the lung, breast and cervix. I am disappointed that there has been little reference – apart from a public meeting I attended some weeks ago in Limerick – to the silent killer, ovarian cancer. I was informed at that meeting that a success rate of 80% is attainable if victims are screened and targeted in time. To walk away from such an opportunity is horrific. Ovarian cancer is a type of cancer that has not been referred to enough despite the huge incidence.

The fatalities per year from cancer among women break down into 500 deaths from lung cancer, 650 deaths from breast cancer and 75 deaths from cervical cancer. These cases should be treatable. Some 20% to 30% of deaths among women could be prevented by a mass screening programme for women aged 50-64. Some 60% of deaths among women from cervical cancer could be prevented by a screening programme for women aged 25-60.

The Minister referred to skin cancer which claims 50 lives per year – a high figure considering that there are relatively few days when Ireland has a high sunburn risk. For all types of cancer, it is not enough to say that we are doing this, that or the other. The Minister should be pioneering. There should not only be screening for a percentage of the population. The target date to have all women screened should not be far off in the future. It should be a high priority to have all women screened now.

Mr. Martin

It cannot be done.

Mrs. Jackman

It must be done. The Mid-Western Health Board does not operate the BreastCheck programme despite Marian Finucane's plea. Women in the mid-west feel badly about this. I am happy for women in Dublin and other areas who have access to screening. However, women in the mid-west must wait, despite its being a huge area.

I am not sure whether additional funding or personnel is required. If it is personnel, it is discriminatory that some areas of the country are better served than others. The awareness is there but I would be happier if services were available around the country. All socio-economic groups of women are terrified of cancer. There is no distinction between middle-class women with access to GPs and those in lower socio-economic groups. It does not matter a damn. All are terrified. The idea of cancer is a horrific shock for individuals and their families. That is the reality for women and it grieves me.

I will refer to a letter which the Minister for Health and Children, Deputy Martin, has received from Cuidiú, the Irish Childbirth Trust. They are looking for three basic facilities in Limerick, where up to 150 people gathered in March to hear a number of guest speakers. They asked for three particular facilities. I am sure the Minister will be familiar with their speakers, Mr. David McVenchie, consultant surgeon, Ms Maeve McGuinness, BreastCheck and Ms Mary Meaney, breast nurse specialist. There was an open forum and a motion was passed that the group would petition for the urgent provision of radiotherapy facilities, a specialist breast unit and BreastCheck phase two.

Considerable anger was expressed at the meeting about the need for their loved ones to travel to Cork or Dublin for radiotherapy. Travelling long distances is, they stressed, extremely difficult for patients at a time when they are very ill and it places a severe financial and emotional strain on them and their families. I am echoing the voices of women at that meeting and not just saying it myself. The July 2000 report on the need for radiotherapy services for patients of the Mid-Western Health Board stated, "In the Mid-Western Health Board region an average of 1,475 new cases of cancer were diagnosed per year between 1994 and 1996". That is an unbelievable figure. The report estimates that 700 of these new cases would require radiotherapy. It stated:

Patients from the Mid-Western Health Board region currently have to travel to Cork or Dublin for radiotherapy. Both of these jour neys exceed the 60 minutes by road limit proposed by the Calmen-Hine report.

I would like the Minister to comment on that. The report also states, "Inequity of access to radiotherapy may mean that best practices are not carried out at all times in all health board regions." I consider that to be a question of equality. There were 152 signatures provided to the Minister in support of the report's recommendations that there be two linear accelerators provided in the Mid-Western Health Board region with link up to Dublin and/or Cork.

They wanted a specialist breast unit established within the region. That is not an extraordinary wish. At present breast cancer services in the health board area is quite fragmented with an ad hoc approach to total patient care, which the people believe has an adverse effect on patient outcome. In order to provide a high quality service and standardisation of breast cancer management, the group recommended to the national cancer forum that one specialist breast unit be established in the regional hospital in Limerick where ancillary services are already available. One specialist breast unit is not too much to ask for. The Minister mentioned that he may not have the back-up or personnel, but they say that ancillary services are already available. That raises a question to be answered.

Breast screening for women aged between 50 and 64 without symptoms is operational, as we know through advertisements, in the Eastern, North Eastern and Midland health boards areas. Does the Minister have a date for the commencement of phase two? I hope he does because that would extend the service to the rest of the country. The people at that meeting felt that it had led to confusion because they heard the advertisements which were broadcast nationally. It placed an increasing pressure on current breast clinics to provide a screening service. The group concluded by saying that health promotion awareness is high on the agenda of the Department of Health and Children. They asked that phase two commence immediately. They asked how many more women would have to become ill before the Department realised the urgent need for this screening programme. I passed the letter sent to me to the Minister and I hope there will be positive answers to the questions it raises.

I want to talk about the need for funding for research on the treatment of ovarian cancer. A recent public meeting hosted by the Adare Zonta Club had heard a number of eminent speakers, Dr. Paula Calvert, consultant medical oncologist to the Midland Health Board, and Dr. Yvonne McGarry, clinical biochemist and expert in the field of ovarian cancer. The latter is currently involved in very promising research with the University of Pennsylvania. The meeting was also addressed by Maureen Hogan, a ward sister in the haematological oncology day unit in Limerick. That meeting was attended by over 150 women. They are in addition to those which I have already mentioned. The big issue was that Dr. McGarry could not get funding. Yet if she produced a particular drug which would help in this area, something that she is in the process of doing, drug companies all over the world would seek to get involved. Because she is in the transitional period approaching a breakthrough she finds its extremely difficult to get funding. She is not asking for very much. She told the meeting that if she secured funding for research that it would have implications not just for ovarian cancer but for other forms of carcinomas.

There are frightening statistics surrounding ovarian cancer. It is the fifth leading cause of cancer among women and the fourth leading cause of mortality. Up to 85% of women suffering from ovarian cancer can be cured if the cancer is detected in the early stages and 30% if detected in later stages. Ovarian cancer is the saddest of all as it is a silent killer. Women, generally those over 60, have their lives suddenly shortened or ended by it.

I am subdued in this debate. I find that there is not a family that has not been affected by cancer. For some unknown reason in recent years deaths from prostate cancer in men, lung, throat, breast and cervical cancers seem to be becoming more common.

An immediate issue on the question of cervical screening is that laboratories are full with test samples. Cytology laboratories need recruitment and retention of screening staff. Automation may improve matters in the long term but St. Luke's is one example where they are getting a week's work per day since the "Coronation Street" story broke. The morale is low, they feel snowed under. They are very frustrated in that they cannot plan towards a catchment area and they want that put in place. University College Hospital in Galway has experienced a similar impact in the aftermath of that story and seek a definition of their workload by catchment area. They are specific issues which the Minister can address.

I urge the Minister that this should become a priority area for the remainder of the lifetime of the Government. There is a need to do something for the young people of Ireland in all areas of cancer but particularly lung cancer.

Dr. Fitzpatrick

We have had an all-day approach on medical matters. We seem to have adopted tunnel vision and focused on specific areas rather than taking an overall view. Senator O'Dowd asked for a discussion on health services – which I concurred with – taking a wide ranging review of where the services are at currently and where they are going.

A lot of the discussion has centred on screening. There is a body of respectable academic opinion which thinks mass screening is not the way to advance and prefers a more focused programme. A fortune could be spent on screening the whole population for cancer. Giving priority to the screening of people with a history of a specific cancer would be a better use of public money.

Senator Henry will be aware that some cancers are almost undetectable until they finally appear. Ovarian cancer is a case in point. Cancers of the abdomen take a long period to be diagnosed whereas brain cancers, because they cause problems at an early stage, can be diagnosed quickly. The position, therefore, in terms of dealing with cancer is not black and white. For example, genetics and environmental factors, smoking, excessive drinking, the leading of a sedentary lifestyle and eating the wrong foods must all be taken into consideration. While none of these by itself causes cancer, if one considers them together, on a global scale, one will find that they can do so.

The purpose of this debate is to discuss cancers which affect women. If one goes into any public house, restaurant or other establishment where people, particularly women, congregate, one will soon see that many young ladies smoke. In my opinion, these women outnumber their male counterparts. The message has, at last, got through to fairly dim males that smoking is not good for them. However, that is not the case with females. We are not getting the message across that smoking not only causes cancer of the lungs but it can also cause cancer in other organs of the body. Smoking does not just target one organ, although it has major effects on the lungs and circulatory system; it can affect every other organ. We are not getting across the message that smoking and people's lifestyles are major causes of cancer. I have already dealt with the genetic causes of cancer and I believe we should target these and press home our message.

As Senator Jackman stated, when one mentions cancer people think of pain and fear. However, those involved in the treatment of cancer will inform you that many cancers can now be cured. Not all cancers are associated with pain and a person's life can be prolonged through treatment. Even people with the most malignant melanomas can enjoy a good quality of life because of the advances being made by oncologists in methods of treatment.

In my profession, medicine, we are approaching the stage where practitioners will be licensed for a set period of years. Continuing medical education will have to become the norm in the next few years. One of the areas in which there is a severe deficiency in medical training for undergraduates, GPs and anyone not involved in the specialised area of oncology is palliative care and pain control. All branches of medicine deal with this area and while individuals who become oncologists, radiologists, etc., may claim they specialise in cancer treatment, it is left to general medical operatives, such as GPs, nurses and others, to deal with the after-effects of treatment. The training these people receive is deficient. I consider myself a case in point in that regard. It is only by attending meetings and speaking with people involved in the area that one might pick up training hints.

I return to my main point, namely, that there is a good story to be told about the treatment of cancer. However, people must be educated and we must inform them about the damage their lifestyles are having on their health. They must also be informed that if cancer is detected early, it can be treated and those affected can, after treatment, return to enjoying life to the full.

Dr. Henry

This is an interesting debate. It is always a pleasure to hear the comments of Senator Fitzpatrick, who has garnered a great deal of knowledge from his daily dealings with people affected by cancer. Perhaps, like me, he received All-Ireland Cancer Statistics 1994-96 in recent days. This is the first occasion on which a joint report on the incidence of cancer and mortality rates therefrom for the island of Ireland. It is a most progressive step that both cancer registries have combined their data and given figures for the entire island, because a great deal more information can be gleaned from considering statistics for five million rather than those for between 3.5 million and four million. I congratulate those involved in producing the report.

Some of the findings in the report are quite extraordinary. I will concentrate on those relating in the main to women. Why is the rate of cancer of the oesophagus among Irish women almost 2.5 times greater than the European average? That is an extraordinary figure. Cancer of the oesophagus is not a pleasant disease either to contract or to deal with. As Senator Fitzpatrick correctly stated and as the Minister of State, Deputy Moffatt, will know, some cancers of the abdomen are diagnosed quite late. Another statistic, to which other Members referred, is the high rate of lung cancer among women in Ireland, which is approximately 150% of the EU average. That is extremely depressing. We must investigate these findings.

We have quite good knowledge of what causes lung cancer. As Senator Fitzpatrick stated, young males appear to have taken to heart the message that smoking is bad for them to a far greater degree than their female counterparts. It is unfortunate, but the fashion industry appears to desire young women to aspire to a particular body image and this is an important factor in terms of the number of cigarettes these women smoke. Apparently, the industry has tried to make up for this by using women who weigh eight stones as opposed to six and a half or seven stones as models in fashion photographs. Many young women seem to believe that smoking makes one thinner. The only way this could happen I suppose is that it is uncomfortable to eat and smoke at the same time. Never having smoked, however, I regret to say that I do not know whether this is the case. For me, eating is quite enough to be going along with.

This is an area we make repeated efforts to address but we do not appear to be making much headway. I commend those young female stars such as Angeline Ball and others who have stated why they gave up smoking. The more we can do to encourage others to do the same the better. As Senator Fitzpatrick correctly stressed, smoking does not just cause lung cancer. New evidence shows that nicotine acts directly on the DNA of the cell of whatever organ is being affected and that it influences the occurrence of abnormal cell division. It is not only the tar content in cigarettes which causes damage, it is also the nicotine.

Other figures from the report which are a cause of concern relate to the high level of colorectal cancer and melanomas of the skin in this country. I know that sunlight is an important factor in causing non-melanoma cancers of the skin. I am not sure, however, that the evidence is quite so strong in the case of melanomas. Should we not do something about banning the use of sunbeds? I am aware that people are warned far more than they were in the past about using sunbeds. Any dermatologist with whom I have contact has informed me that sunbeds are a bad idea. However, some people seem to believe their skin should resemble the leather on the old saddlebags one sees on camels travelling across the desert. Should we not make a better effort, given the high rate of skin cancer and melanoma, to try to stop the use of sunbeds? I know using a sunbed is supposed to make one look more healthy, but I believe people are beginning to realise that the pale look is what is required. I urge other Senators to consider the figures to which I refer because they are important.

I welcome another development which came to light today. I refer to the initiative from the Health Research Board and the Women's Health Council which seeks projects for research. The projects are very wide in scope and can range from clinical trials to epidemiological studies. This is good because, if we do not know something of the epidemiology of a disease and its natural history, it is very difficult to do much in the way of treatment. I commend the Minister for investing money in this area. I wish those who take part in these research programmes well. I am delighted to see they will be paid slightly better than usual. One sometimes wonders who would take part in these research programmes given that the pay is so bad. Those with PhDs are to be paid £10,000 a year whereas the normal rate is about £4,000.

The Minister and others rightly praised BreastCheck which has been a great success in so far as it has gone. As the Minister of State is aware, it takes place in a limited part of the country. Having been part of it myself, I can say it is extremely well run. Deputy Owen said that, if the rest of the health service was as well run as BreastCheck, the situation would be quite cheerful. The centre I attended was attached to St. Vincent's Hospital. The notification was good, the appointment system was excellent, those in reception were very good, the waiting area was first class, the radiographers appeared to be very well trained, one was given information, which in my case, fortunately, was fine, within a few weeks, and those who required further investigation – I know a few personally – felt they had been dealt with very well. I am disappointed it has not been possible to extend BreastCheck to the rest of the country. As far as I can see from advertisements in the newspapers, the major problem is hiring radiographers, of whom there is a great shortage. The programme cannot be extended without experienced and well trained radiographers to take mammograms.

What is worse is that I saw in one of the medical newspapers recently that Dr. Jane Buttimer is reported to have resigned as head of the programme. This is very bad news because she set up the scheme and has run it since. It almost has a 70% recall rate, which is excellent. Most schemes, if they are as good as that, say they are not doing too badly, because there will always be some who will not go. I would be very glad if the Minister of State would let me know if it is true that Dr. Buttimer has left the programme because, if she has, that is very bad news. As the Minister of State sometimes runs off without answering my questions, I would be grateful if he gave me an answer to this one because it is very important.

The symptomatic breast disease clinics as recommended by the cancer forum are not doing badly. General practitioners to whom women, and the occasional man, come with symptomatic breast disease, such as a lump in the breast, discharge from the nipple and thickening of the skin over the breast, refer them immediately to these clinics where the necessary investigations are conducted that morning. All the results are collected together and those involved in the treatment of breast disease, such as surgeons, oncologists, physiotherapists, cancer counselling nurses and radiotherapists, meet a few days later and discuss a programme of treatment for the woman concerned.

These types of clinics appear to have a better success rate in the treatment of symptomatic breast cancer than clinics which perhaps have a radiotherapist call once a month and the service of an oncologist 50 miles away. The Minister of State should hold his courage and show people how important it is that they are referred to these clinics rather than being seen in hospitals throughout the country. We all become attached to small local hospitals but it is sometimes wiser to attend a centre of excellence to try to achieve a better result. Years ago I compared the results of the major cancer units in America and France with ours, noticed how much better they were and did not think we could achieve them. However, some specialist clinics in Ireland claim good results and it is important we should try to let the public know the importance of this.

One fifth of cancer deaths in women are due to breast cancer. With more modern treatment, we should be able to do something about this. The genetic element apparently only accounts for about 4% to 6% of cases, but it is important to identify women in this group because, if there is a genetic susceptibility within a family, we may want to screen earlier and more often. Senator Fitzpatrick made a good point when he said that, in screening, there must be a common condition and that, if it is detected, we must be able to do something about it for it to be worthwhile screening. We can do this with breast cancer.

Senator Fitzpatrick was correct in saying that we must try to be selective in screening susceptible groups in some situations. This may be the situation with ovarian cancer. We are inclined to find ovarian cancer when, regrettably, it has progressed considerably. However, there is a genetic link between that form of cancer and a genetic susceptibility to breast cancer. Perhaps the grouping with which we must first deal in screening for ovarian cancer should be those in the group genetically susceptible to breast disease. This is an important issue because the development of and death rate from ovarian cancer in Ireland is quite high.

The Minister and Senator Jackman both referred to cervical cancer and it is unfortunate that those most likely to have it, namely, those in lower socio-economic groups, are least likely to come forward. Cervical screening for cancer is a very emotive subject with some women but we have not done it properly yet. It is impossible to say it has not been very successful when we have not tried it properly. Has the Minister of State noted that good progress is being made on vaccines for cervical cancer? It is a sexually transmitted disease emanating almost certainly from viral infection of the cells of the cervix. Perhaps we should try to get work going in this area. There is none in Ireland of which I am aware but it could be useful in preventing deaths from cervical cancer which are always preventable. Cervical cancer does not spread rapidly and, if detected early, the removal of the uterus results in a good cure rate. It is disappointing women do not become more involved in screening for cervical cancer.

Perhaps we should try to do more research in the areas of breast cancer and diet. We are aware that obese women are much more likely to get breast cancer than slimmer women. The possibility that obesity affects the production of oestrogen and progesterone which affect breast tissue is important. At one stage it appeared that countries with a high intake of dairy products, such as ourselves, had a higher incidence of breast cancer. These are areas of which the Health Research Board and the Women's Health Council could perhaps take note and ensure various projects are established within them.

It is important that we have an extension of facilities for oncology and radiotherapy, which are in very short supply. St. Luke's Hospital in Dublin has been up-graded, but not before time. Some of the machinery in Cork would be suitable for a museum. There have been dreadful situations when machinery has broken down and patients have had to travel from one hospital to another by train. There have been improvements in the supply of equipment in Galway, partic ularly for radiotherapy. However, it is extraordinary to see oncologists and radiotherapists being appointed to units which do not have the facilities they need.

Some efforts are being made but much remains to be done. More needs to be done in research, epidemiology, screening, treatment and the improvement of facilities. I support Dr. Fitzpatrick's call for training in palliative care for the medical and nursing professions.

Miss Quill

I welcome the Minister of State to the House. The House is lucky in having access to the insight and experience of medical practitioners such as Senators Mary Henry and Dermot Fitzpatrick. Their knowledgeable contributions to the debate have made it very valuable. It would not be right to discuss the topic of women's health merely from an academic viewpoint. It is good for the Minister of State and those who make important political decisions to hear these insights. I acknowledge the contributions made by our medical Members, as well as other.

Credit is due to the Minister for Health and Children and his predecessors for approaching cancer in the manner in which it has been approached and for identifying cancer as a major killer in our society. The Government's approach to cancer has been ring-fenced in a coherent way by the putting in place of a national cancer strategy and by establising the cancer forum. There is now a coherent approach to cancer.

Cancer is a major killer and many of its victims die needlessly. The disease could be prevented in many cases and prevention should be the primary objective of any cancer strategy. When cancer strikes a family, particularly when it strikes a young mother, the disease visits anguish on every member of the family and not merely on the victim herself. The anguish experienced by the surviving spouse and children is difficult to understand if one has not had direct experience of it. Anything which can be done to prevent cancer should be attempted.

The major pillars of the national cancer strategy are prevention, early detection, treatment and palliative care. Mention has been made in every contribution this evening of the direct link between smoking and cancer, particularly lung cancer. The Minister for Health and Children is striving with might and main to come to terms with the tobacco companies, to reduce the instances of smoking and to reduce access to tobacco and cigarettes by young people and by people of all ages. The Minister is right in what he is attempting to do but in his efforts he reminds us of David fighting Goliath.

Because of the large number of very young women who are smoking I am convinced that prohibition alone will not achieve the Minister's objective. There is a tendency in all young people to go against authority. If something is forbidden it takes on an added appeal. I am not convinced that the problem will be solved at the level of prohibition. Our education system must include a physical education syllabus with an emphasis on lifestyle, wellbeing and respect for one's own body. Such a programme must be built into our education system from the nursery classes up to leaving certificate level. Respect for good health would derive from a well-designed and well-delivered programme of education which should be built into our education system and should become an examination subject. This is the only way to approach the scourge of smoking and drinking among our teenage population.

The NCCA is preparing a new physical education programme but I understand it is not intended to make it an examination subject. This subject should be assessed within the school throughout the pupil's school career, as well as in a written examination at leaving certificate level. In its recent report, which has been widely leaked although not published, the NCCA points out that much of what is measured in the leaving certificate examination has little intellectual, emotional or vocational value in later life. I believe this to be the case. Is it not sad that young people waste time in school on matters which have so little value in later life? Can we not make time for young people, in their formative years, to cultivate a healthy approach to their personal lifestyles? We must think very carefully about the benefit of putting properly designed programmes of physical education at the heart of our education system if we are to root out the awful habit of smoking.

We must also try to reduce drinking among young people. I was less than impressed this morning when I heard a spokesperson for third level students respond to something said by Dr. Don Thornhill about teenage drinking by saying he would bet there was more drinking per capita in the Dáil bar than in any student bar. If that was his reasoned approach to a serious topic, I wonder how much that student has learned about the assembly and presentation of evidence or about taking a serious approach to a very serious issue which is doing irreversible damage to many of his peers. The student's response was so glib it made me blush.

These are the issues we must confront. The figures for the incidence of lung cancer in Ireland are 50% higher than in any EU member state. A direct link has been established between smoking and lung cancer and we must, therefore, take this issue seriously.

I agree with what was said by Senator Henry about sunbeds. There should be no ambivalence about this matter. Sunbeds should be banned. We now know definitively, on foot of the best available research, that sunbeds do damage, including causing skin cancer, which is a prominent feature in this country. Sunbeds should be banned outright and why we do not do so defeats me. I know of places where children received sunbed treatment in preparation for making their Holy Communion. I am not exaggerating – it is true. The Minister should grasp the nettle and ban sunbeds. Many people would be grateful later if that was done and it would be a major step towards preventing cancer. The old proverb "prevention is better than cure" is certainly true in this case. Once cancer strikes, it hits hard and unless one is lucky it can be terminal. Prevention should be the main plank in any strategy to prevent women's cancer.

I hope that what I have said will challenge politicians. While I am glad the Minister of State, Deputy Moffatt, is in the House to provide his professional expertise as a medical doctor, I am sorry the Minister, Deputy Martin, has had to leave. He was such a vibrant Minister for Education and Science and I would like to have put my points to him concerning the importance of physical education. Senators might seek to organise a debate on that issue fairly soon, however. We all feel strongly about cancer, about playing our part in trying to protect young people and preventing the prevalence of cancer.

After prevention, early detection is the next most important issue in fighting cancer. Like other speakers, I pay tribute to BreastCheck for the work it has done. The breast screening service took initiatives on foot of the knowledge that breast cancer was such a major killer among women. BreastCheck identified the age groups where it was most lethal and developed the breast screening programme. We must intensify that work. Senator Fitzpatrick suggested that we should target certain families with an identifiable predisposition for cancer, rather than carrying out a universal breast screening programme. We should put more time into testing such people early and often.

The term of office of the special adviser on cancer services, Professor Fennelly, has expired. As I have not been able to establish if his replacement has been appointed, will the Minister provide us with that information? It is important to have somebody in that pivotal position if we are to drive the agenda of this cancer strategy through the National Cancer Forum. The appointment should be made without delay.

We need to train more radiographers because their work is an essential element of the early detection of cancer. That work should be intensified. We need to expand access to radiotherapy services. Senator Henry spoke about the importance of clinics having an integrated approach, not just on a regional basis but bringing them as near as possible to patients. I am aware of the anguish some patients suffered, particularly when the oncology and radiotherapy equipment in Cork city was, like the train service at the time, working some days but not others. Much anguish was inflicted on patients by that problem which has since been remedied by the Minister. It was appalling that women had to travel long distances for treatment elsewhere, thus adding to their pain and suffering. We should aim to extend treatment facilities as near as possible to the patients concerned.

Palliative care has proved to be invaluable in the overall approach to cancer. Such care confers benefits not alone on cancer patients but also on their families. The Sisters of Charity in St. Patrick's Hospice in Cork, who were pioneers in the field of palliative care, are next door neighbours of mine. I taught in a school run by that order with which I have many connections and, consequently, I know about the benefits of palliative care for cancer patients. Dr. Tony O'Brien, who works in St. Patrick's Hospice and who has had first-hand experience over a prolonged period of the benefits conferred by palliative care, has carried out a review of the current provision of such care. When that review is published we should debate it in the House with a view to heightening awareness of the benefits of palliative care.

A sufficient number of palliative care nurses are required to provide supportive care as an integral part of our overall approach to cancer treatment. I welcome the opportunity to debate this serious issue and I am satisfied we are going in the right direction. I hope sufficient numbers of qualified staff and facilities can be provided to enable the objectives of this strategy to be achieved within the specified timeframe.

Ms Keogh

I am delighted to have the opportunity to speak in this debate. I wish to refer to what one may consider an unusual analogy. A decade or so ago, car manufacturers completely transformed the way in which they made cars. They stopped stockpiling components and moved to a "just-in-time" delivery system. They drastically reduced the types of components they needed to use. They worked closely with their suppliers on quality and timeliness instead of beating them down on price. They eliminated waste by making all workers, not just inspectors, responsible for quality. The result was that new models took less time to develop, the quality improved and cars could be made to order for each customer. At the same time productivity improved and costs fell.

More recently people in health care have realised that their service has a long way to go to match the performance of other industries, both in terms of manufacturing and service. Reports in many countries have documented the size of the gap between the best care that can be delivered to patients and the care they actually receive. Health systems fail to provide treatments that are known to work, persist in using treatments that do not work, enforce delays and tolerate high levels of error. Like car manufacturers, health leaders recognise that the health care system needs radical redesign.

There is an infinite number of issues surrounding the provision of cancer treatment and support services for women, as we have already heard in this debate. I will confine my remarks to three main areas which are extremely important. The first one concerns breast cancer. It is a sad fact that the incidence of breast cancer in Ireland is among the highest in Europe, with over 1,200 new cases being diagnosed each year. Hereditary factors, alcohol, smoking, increasing age, late first pregnancy, late menopause and living in a western developed country are some of the factors cited as increasing the risk of breast cancer. As the causes of breast cancer remain to be established, however, it is not known how it can be prevented and therefore the emphasis is being placed on early detection through physical examination, mammography and early treatment. This year more than 600 Irish women will die of breast cancer. In its 1995 discussion document, Developing a Policy for Women's Health, the Department of Health and Children pointed out that about 20% to 30% of deaths from breast cancer in women over the age of 50 could be prevented if a quality mass screening programme was in operation.

I must admit to wearing another hat in this debate since I am chairperson of the Well Woman Centre. I welcome the almost nationwide establishment of the BreastCheck programme, which should go some way towards reducing the mortality rate among Irish women. However, the programme has been hamstrung by skills shortages, meaning that it has not been able to attract sufficient numbers of medically qualified personnel to operate effectively. Senator Henry referred to the shortage of radiographers. I question the reason BreastCheck has not yet been rolled out nationally and no schedule is available as to which geographic areas it will service next, even in health board areas where it has been established.

A recent experience in a Well Woman clinic was that of a woman within the target age group living in Poppintree, Dublin, who did not receive a letter from BreastCheck but was aware of friends in the area who were called for mammograms. She assumed she would be called but was omitted completely. When one of our doctors rang BreastCheck to find out what the problem was, she was told the woman was not on the register and BreastCheck would not be back in the Poppintree area for two years. Getting a routine screening mammogram through the public system is almost impossible. For example, St. Vincent's Hospital stopped taking routine appointments for mammograms almost 18 months before BreastCheck started because it was gearing up its services for the programme. In the other main centre in Dublin, the Mater Hospital, staff will often not answer the telephone in the mammogram section of the X-ray department or they will refuse to take the patient's name and ask her to call back in a number of weeks or months. If she is very lucky, she may be given an appointment far into the future.

The woman from Poppintree was in the at-risk age group and the only two options open to her were to pay privately for a mammogram – currently costing between £50 and £80 – or for Well Woman to refer her to an already overworked breast clinic where the average wait is approxi mately three weeks. Well Woman had to add an extra patient into an overloaded system because the patient had fallen between the cracks in the BreastCheck system.

BreastCheck's success or failure will be largely influenced by the lack of a comprehensive, accurate national population register. There are, without doubt, many women who will fall between the cracks in BreastCheck. A more accurate population register could have been created for the programme and other screening programmes by implementing a universal registration system such as the use of RSI numbers. It is almost impossible for Well Woman and general practitioners to recommend and effectively promote the BreastCheck service to women in a timely fashion when there is no relevant follow-through in provision of service.

A possible conversation in a consultation, as illustrated to me by a Well Woman doctor is as follows: the doctor tells the patient she should go to BreastCheck for a mammogram. She asks when will that be to which the doctor replies that he does not know. The patient then asks if the doctor will find out to which he replies no because he will not be informed which area BreastCheck will write to next. That is not the way to run a service.

Apart from BreastCheck, the experience of women attending breast clinics for symptomatic reasons is also less than positive. Despite women accessing the service and health care professionals providing it sharing largely the same objectives and concerns, a report published last year by the Women's Health Council found there were frustrating delays in all aspects of the service from getting a first appointment to delays in the clinics because of pressure and delays in getting the necessary diagnostic tests. Sometimes various test results came back at different times, requiring women to return, perhaps more than once, to speak to the relevant staff member. There was no reimbursement of costs incurred in travelling available to medical card patients.

Women felt they were not provided with enough information on their illness and there were insufficient numbers of staff within the clinics, particularly specialist nurses, to listen to their concerns and fears and answer any questions they might have. Women did not feel the breast care nurses had a specific brief and were being diverted into administrative tasks rather than being available to provide patients with care and support. They felt there needed to be expert medical advice available to them at weekends, especially when they were undergoing treatment such as chemotherapy when they were quite likely to be ill afterwards. The breast care support system shuts down at weekends. Breast disease causes not only physical illness, but mental and emotional distress also. Women felt there was a need for trained counsellors, psychologists and other trained support staff to be available through the breast clinics.

The second area which I wish to address is cervical cancer from which more than 70 women die each year. It is almost entirely a treatable condition if picked up in the pre-malignant, pre-cancerous stage. Women are dying unnecessarily because there is no national mass screening programme in Ireland. The Plan for Women's Health, published in 1997, states, "A national screening programme will be established in 1999, or earlier, if resources permit". Even now, in 2001, only the Mid-Western Health Board area screens for cervical cancer. The need for a pilot study is questionable given that international studies clearly demonstrate that a properly implemented screening programme is effective in reducing the mortality rate among women.

Well Woman is well qualified to speak on this matter as it takes more than 7,000 cervical smears each year from women who present at our clinics. The Plan for Women's Health aspires to assist cervical cytology laboratories, that is, testing laboratories, to deal with heavy workloads as part of the implementation of the national cancer strategy with the aim of ensuring the results of cervical smear tests are available as far as possible within one month. It is Well Woman's experience that, on average, smear test results take ten weeks to come back. This delay has been a consistent factor in the past two to three years and is not limited to any single laboratory. Delays in results give conflicting messages. Clinicians tell women it is important that they have a smear taken but, at the same time, the health care system tells them it is not important enough for results to be returned in a timely fashion.

If the smear test result warrants further investigation, the next stage is referral to a colposcopy clinic. The waiting time for a public appointment is another eight to ten weeks. It is not unusual for a Well Woman clinic nurse to spend up to half a day on the telephone trying to obtain an appointment for a woman, particularly if it is urgent, where the clinic's doctors suspect the presence of cancer. The patient can always choose to go privately, in which case the cost of a colposcopy can be more than £200, with insurers picking up some of the cost. However, even then, there is a waiting time of two to three weeks within the private health care system. The anxiety felt by women at every stage of the system, whether they are public or private patients, is considerable.

One Well Woman client, who presented with symptoms highly suggestive of cervical cancer, was referred by us and got a colposcopy appointment which showed cancer. The hospital gynaecologist referred her to a cancer treatment specialist. Unfortunately, this happened in mid-December 2000 but she was not seen until the second week in January. She was so distressed by the delay that she returned to Well Woman for advice and reassurance. As it turned out, she had invasive cancer. Had there been an effective mass screening programme in place the woman would probably have been called for a smear test on a more regular basis and might be alive today.

Laboratory services in the State are completely overwhelmed, and the Department of Health and Children needs to examine ways to ease the bur den and support new technologies to do so. Liquid-based technology to analyse smear samples has been widely proven to be more accurate. It has the advantage of being more accurate and, therefore, reducing the number of repeat tests required, thus reducing pressure on laboratory facilities. This technology also reduces the anxiety caused to women by inconclusive results, which require them to repeat the test, and gives medical and nursing staff greater confidence in the testing process, as well as allowing them to work to current best practice. Well Woman adopted this new technology last year and recommends that the national cervical screening programme, whenever it is rolled out, should also do so.

Testing for particular types of HPV, human papilloma virus, has also been shown to be an accurate indicator of whether a woman is at high risk of developing cervical cancer. Such a test is currently not available in Ireland, yet it could be undertaken at a relatively low cost as the test is done on the cervical smear sample. It is a highly accurate test, which would have the effect of reducing the number of colposcopies required, thereby reducing pressure on the hospital system. An accurate screening programme would not only save lives, it would also cut costs in the health care system.

The third area I would like to mention is ovarian cancer for which there is no accurate test. In many ways, it is the forgotten cancer. It is considered by many in the field that it may kill as many women each year as cervical cancer, yet the Department's Plan for Women's Health makes no mention of it. Some ovarian cancer is genetic and there are links between breast cancer and ovarian cancer. This can sometimes be detected by looking at family groups. Pre-menopausal women with close relatives who have had ovarian cancer and/or breast cancer should therefore be automatically informed of the increased risk of cancer.

To do that effectively requires dedicated staff resources and genetic counselling along with test facilities, surgical and oncology support. That is currently being done in the Dublin hospitals as a research project. The experience in other countries suggests that a combination of genetic testing and family history can quantify the risk of cancer. High risk women can then be monitored by means of pelvic ultrasound scanning and blood testing for specific cancer markers.

We have the ability to deal with these issues but we do not have the type of service that can deliver in that regard. Simply throwing money at services has not worked. We need a radical redesign of our cancer care services just as we need a radical redesign of our health care services. This is one of the most important issues on the doorsteps.

Dr. M. Hayes

I welcome the Minister of State to the House. I welcome the debate also which I have found most instructive. I gained a great deal from the professional experience and knowledge of Senator Fitzpatrick and Senator Henry and from the evocative cry from the patient voiced by Senator Keogh.

I congratulate the Minister of State on the progress made through the national cancer strategy. We should get behind that strategy to ensure that it is rolled out before we talk about other radical changes.

I am glad the Minister talked about lifestyle, particularly the relationship between cancer and smoking and alcohol. The continued advertising of smoking and the linking of alcohol with sporting events is something that should be tackled. I know the Minister of State might have less interest in the Guinness hurling championship than some of the rest of us but, nevertheless, it is something he might examine.

There is the difficulty that the greatest increase in smoking is among women, particularly among women in the D and E social grades. We have been told that these are the people who are most susceptible to various forms of cancer.

I welcome the links that exist between the national cancer strategy and the cancer strategy in Northern Ireland and the National Cancer Institute in America. Each of those is benefiting from international research. It is clear now that there are better outcomes for patients who are treated in multi-disciplinary centres which handle a large volume of cases, particularly the more unusual cancers. I would encourage the Minister of State, therefore, to bite the bullet and maintain a degree of specialisation and centralisation that is needed to assemble teams of that size and for that purpose.

In that context, I question the investment of large amounts of money in new equipment in a free standing hospital like St. Luke's. Increasingly, these institutions need to be brought together on the campus of a large general hospital which, among other things, will help to remove much of the mystery and fear of cancer. In that regard I congratulate the Minister on coming here for this debate because it enables us to discuss this issue and remove some of the mystery surrounding it so that people can see the improvements that have been made and the possibilities that exist of improving outcomes through early detection.

If treatment is to be decentralised, diagnosis and screening should be brought as near as possible to those people we are trying to reach. The difficulty of all screening programmes is attracting the very people that are most needed. We talked about that earlier. Much of the screening is opportunistic and I share Senator Fitzpatrick's scepticism about the efficacy of universal screening programmes. In terms of health economics, some of them are questionable and perhaps we would be better putting our money into other areas. Targeted screening is important, particularly for young, sexually active women who, as Senator Henry said, are increasingly becoming vulnerable to cervical cancer, a sexually transmitted disease which needs to be treated as such.

To come back to the question of centralisation, there is a temptation to try to spread the goodies too thinly but it is important to build up fully staffed and properly equipped centres and then roll out the programme rather than try to maintain a weak centre and a weak periphery. That requires a certain amount of political fortitude, not only in terms of the ordinary politics we deal with but the much more dangerous medical politics of which the Minister of State would be aware.

There is much to be said for support for the hospice movement and the development of palliative care. Great results have been achieved from home nursing of people at terminal stages of cancer which transforms the quality of life for the patient and is of enormous support to families as well. Underlying all of that, however, is a need for quality control. The figures Senator Keogh quoted are indefensible in terms of people having to wait months for screening or testing. Many cancer cells can grow in that period of time.

On the question of waiting for results, it is interesting that when there was an economic motive we were able to get results back quickly on foot and mouth testing yet these women have to wait for test results. That points to a need to examine the laboratory service and to ensure it is fully equipped and that quality is maintained. We have seen what happens in other jurisdictions when there are false readings. The only thing worse than a false negative is probably a false positive and the amount of concern that causes.

I repeat my three points to the Minister of State. First, do not weaken on the question of concentrating treatment in large, multi-disciplinary centres. Second, decentralise diagnosis and screening to the extent that it is possible and, third, underpin the whole service with a proper laboratory service, all of which is amenable to quality control so that people can be told how long they have to wait before their tests come through.

I congratulate the Minister of State on the progress that has been made and the evident concern he has for the welfare of women. I wish the national cancer strategy well.

Mr. O'Dowd

I welcome the Minister to the House. This has been an important and useful debate and I was impressed by the contributions from all sides of the House on the issue.

I want to make a number of points about cancer. I got a telephone call some months ago about the BreastCheck programme in the north-east. The programme is widely advertised in the North Eastern Health Board area covering counties Louth, Meath, Cavan and Monaghan. Women in the age group 50 to 64 are being asked to get in touch with the BreastCheck programme, which they do, but when women in County Louth rang up to inquire about it, they were told that the programme would get in touch with them about their appointment.

A number of these women were very concerned about that issue and they got in touch with me, following the advertisements on radio and television – I believe Marian Finucane was on national radio – to know when they would get their appointments. I have discovered that it will be the end of next year before the BreastCheck programme is available in County Louth. Regrettably this is creating much concern among people who have seen the media advertisements, including those in bus shelters. However, the service is not available in County Louth. There is nothing wrong with the service being offered in County Meath. However, the advertising should be restricted to the counties in which the service is operating. Otherwise a demand is created which cannot be met. This is causing stress, distress and upset to many people.

The female doctor mentioned earlier informed me that it is hoped to have a new unit in place by the end of this year. However, the service is under much pressure to attract the highly qualified staff required. Perhaps the Minister of State can confirm that attempts are being made to recruit staff from as far away as Australia and New Zealand. I welcome the thrust of the policy but the Government cannot provide the qualified staff. It is unacceptable that the service is receiving further publicity in areas where it cannot be provided for almost two years.

I also wish to raise the issue of women over 64 years or under 50 years. Older women have asked me why they are being excluded from the service. Do these women not face the same or, perhaps, a higher risk? I am not getting away from the medical opinion to the effect that women in the 50 to 64 age group are at the highest risk. However, what about older women?

I asked my local health board what facilities it would make available for a woman in County Louth who could not get an appointment under the BreastCheck programme. This woman is concerned that she may be in the age group susceptible to cancer and wonders what she can do. What can this woman or her doctor do? I am told her doctor can do nothing as one cannot undergo a mammogram in the north-east, and, I think, in most areas, unless one is referred by a consultant. A GP cannot refer a patient to a local hospital. He or she can only refer someone to a consultant. There are many problems in this area.

The excellent equipment being used in the BreastCheck programme is not available in general hospitals. This is creating significant problems. A woman cannot obtain a routine mammogram unless she goes to a consultant, or she is living in a county in which the programme is in operation. This is unacceptable. The Minister must make changes to the system to ensure that the service is more widely available and to attract the professional staff required to run the programme.

I also wish to raise an issue which arose yesterday and which shocked me greatly. I am a member of the North Eastern Health Board, but I was unable to attend a meeting yesterday for family reasons. At yesterday's meeting, the health board discussed a proposal from cancer specialists that the centres of excellence for breast screening in the north-east should be based at Our Lady of Lourdes Hospital, Drogheda, and at Cavan hospital. However, the male members of the board decided by a majority of two votes to accept the recommendation of the cancer specialists and the deputy chief executive officer of the health board, who is in charge of the programme, but to base the centre in Navan rather than Drogheda. This is a short distance – 20 to 30 miles. However, the breast cancer consultant in the north-east has informed me that the effect of this decision will be that women who are seriously ill with cancer, or those who will develop cancer, will wait about two years longer to get the service if it is moved from the proposed site in Drogheda to Navan.

I support Senator Maurice Hayes's comments that the Minister must insist that people do not play regional or local politics with this decision. The location of centres of excellence for the treatment of cancer, or any illness, must not be left to petty politicians who play their parish pump games with an issue which is far too serious. Cancer services must be above politics. All political parties agree on what should happen, but we should listen to, and follow the advice of, the experts. This decision is not a matter for the Minister and it appears he cannot intervene. It is a matter for the health board, but what has happened is disgraceful, reprehensible and unacceptable. I hope the Minister will use whatever influence he has with the members of his party who voted for this change, as I will do with mine. I will also ask my party leader to do the same.

Cancer is a tragic illness. Working together as a community and a State we must provide more funding for cancer services. I support the changes made. However, we must examine the issue of research and development. Some cancers do not receive priority in this regard. Cancer of the pancreas, for example, accounts for 4% of all cancers, yet 25% of deaths from cancer. Diseases such as this are receiving no funding in America. We should ensure that the different kinds of cancers, whether they affect men or women, are properly and adequately researched. We should examine this area closely.

I agree with the comments made regarding malignant melanoma – skin cancer. The Minister of State may be able to propose that pop idols such as Bono and others, who already significantly impact on the lives of young people, are used in advertising campaigns regarding health issues. Reference was made to the Guinness hurling championship. Perhaps we should call it the cancer hurling championship. We should focus on issues such as cancer in the sense that the big game is to beat cancer. It would not take many minds to work together on this issue.

I agree that the abuse of alcohol and tobacco is significantly affecting the lives of young people. It is unacceptable that this continues. We can talk about this issue but let us see some action. Someone diagnosed as having cancer should be given an information pack by the family doctor, consultant or whoever. People should be given the contact number for the Irish Cancer Society which does excellent work. Many hospitals have their own oncology nurses and oncology units. However, some people slip through the net. The support services which are necessary for those diagnosed with cancer should be increased significantly. These groups should receive more funding and recognition. I support the comments made regarding palliative care and the hospice movement which does a fantastic job. I acknowledge the tremendous work which is done in my area and my town.

This has been an important debate and the Minister of State has taken note of the points raised. So many people are dying from cancer that we must do more to help them. In this regard this debate has been constructive.

While there are specific Internet sites in Ireland with information and help for families when a diagnosis is made, there are not enough. More could be done to provide information on the Internet regarding the different types of cancer. Much of the information on the Internet is from institutes in America, so more is required emanating from Ireland. I am pleased to have had the opportunity to listen to the views expressed in this important debate.

Mr. Glynn

This debate is important. Women play a pivotal role in society. I do not wish to be patronising when I say that they bear our children and rear them. Much of what I wished to say in this debate has been said, so I will not engage in repetition.

On the question of cervical screening the Minister stated:

The National Registry Board reports that between 1994 and 1997 cervical cancer accounted for an average of 74 deaths in Ireland each year, with cervical cancer being more common in older women. The report, entitled Developing a Policy for Women's Health, states that while cervical screening is simple, quick and relatively inexpensive, not all women respond to requests to attend for screening. It has been found that women in the lower socio-economic groups may fail to do so and it is mainly among these groups that deaths from cervical cancer occur.

There is a major need for ongoing information and contact, especially with the groups referred to by the Minister. It is important to target a programme at girls at second level and especially third level. They should be told that in seven or eight years they will fall into the age category referred to by the Minister when he states: "Experts in the Europe Against Cancer programme recommend that women between the ages of 25 and 60 years should have a cervical smear regularly and that they should participate in organised screening programmes where available".

It is important to review and amend strategies, including the national cancer strategy. Major progress has been made on implementing the strategy. At national level the main infrastructural elements have been put in place. These comprise the establishment of the National Cancer Forum to advise on the implementation of the national cancer strategy. The first forum met between March 1977 and April 2000 and the second forum has held two meetings – a third meeting is scheduled for May 2001. The term of office of the special adviser to the Department's cancer services, Professor Fennelly, expired on 1 April 2001. As a member of the Midland Health Board, I benefited from some of the professor's wisdom, for which I thank him.

The Minister referred to the appointment of regional directors for cancer services, which was an important step forward. The establishment of a steering group, chaired by Dr. Sheelah Ryan, chief executive officer of the Western Health Board, to organise a national programme of screening for breast cancer is also to be welcomed. Dr. Ryan is an experienced general practitioner and medic. She was director of community care during my time on the Midland Health Board. She then progressed to become programme manager and, ultimately, chief executive officer of the Western Health Board. Given her experience, the steering group under her chairmanship is in safe hands. I commend the Minister and the Department for ensuring this.

Dr. Michael Dowling of the Rotunda Hospital has been appointed chairman of the advisory committee to oversee the establishment of a national cervical screening programme. He is doing excellent work. The Health Research Board was allocated a grant of £80,000 per annum for each of the years 1997 to 2000 for the coordination of multi-disciplinary, multi-institutional research as indicated in the national cancer strategy.

There has been a common approach by the Minister for Health and Children and his Northern counterpart working in tandem with the authorities in the US. A historic memorandum of understanding has been signed to establish an Ireland-Northern Ireland cancer consortium. This will result in the development of joint cancer research programmes, scholar exchange programmes and a range of other collaborative activities, all of which are very important.

The Minister referred to the number of consultants appointed to the various health boards, which is very welcome. All the boards, including the one of which I am a member, have benefited. We should not be reticent in reviewing this strategy in view of changes to medical practice. There are new developments every day and for this reason it is important that we review what has been done, consider what must be done in the future and implement the best possible practice.

An Leas-Cheann Comhairle

That concludes statements. When is it proposed to sit again?

Mr. Glynn

At 10.30 tomorrow morning.

The Seanad adjourned at 5.40 p.m. until 10.30 a.m. on Wednesday, 30 May 2001.