I appreciate the opportunity to speak to the House on this important issue. I have listened very carefully to the views of Senators in relation to the extension of the BreastCheck screening programme. I hope to deal with some of the issues they have raised. I have no disagreement with the essential tenet of what is being said in relation to the need for an extension of the breast screening programme. I have publicly expressed my commitment to the extension of BreastCheck and did so at the launch of the BreastCheck annual report.
My commitment is based on principles of equity. Women in the 50-64 age group should have access to the same level and quality of service, regardless of geography. The BreastCheck programme is for women aged between 50 and 64 years. This applies equally to breast screening services, access to breast surgery and oncology drug therapies which combined are essential elements in an effective breast cancer programme. It is the combination of these modalities of care, with radiotherapy, which are required if we are to reduce mortality rates from breast cancer. That is the reason we take issue with the nature of the debate so far on BreastCheck in that there has been an attempt to almost isolate it from every other component part of a breast care programme. That is a huge mistake. Let us remember also that women who present with symptomatic breast disease are entitled to as rapid access to care as those who go through the BreastCheck programme. The combined nature of the different modalities of care coming together is the key point. I will flesh this out later.
I accept that Irish mortality rates are out of line with European data and need to be reduced. It is important to state the vast majority of women with breast cancer will be diagnosed and treated outside the national screening programme. Judging from the debate in recent weeks one would imagine BreastCheck was the be all and end all of saving lives. It is not. I argue that prior to 1997 – I do not mean this in any political sense – we were not treating cancer properly and not responding to it in any sophisticated focused programme in line with international best practice which would guarantee better survival rates and a better outcome.
While incidences of breast cancer rise dramatically in older women, breast cancers still make up a high proportion of all cancers in younger women. National Cancer Registry data show that 35% of breast cancer cases occur in women in the 50-64 year age group. Because the screening programme deals only with women in the 50 to 64 year old age range and only those who have no symptoms, the great majority of women with breast cancer will continue to be diagnosed and treated outside the screening programme. For this reason and because of the need to investigate and treat the large and increasing number of women with breast symptoms due to benign conditions, it is necessary to develop and support both the symptomatic and screening services to ensure a comprehensive cancer service for women.
I am pleased to have an opportunity to speak on the Government motion which concerns a broadly based cancer programme within which breast and cervical screening are important components. The significant progress made in terms of the growth in funding available for the sector in recent years is indicative of the Government commitment and mine, as Minister for Health and Children, to the ongoing development of cancer services.
Since 1997 there has been an unprecedented level of investment in cancer services. Since the implementation of the national cancer strategy a cumulative figure of approximately €400 million has been invested in the development of cancer services. That represents an average increase of almost €60 million annually, well in excess of the £25 million initially envisaged in 1996 when the national cancer strategy was devised. It was thought that £25 million per year would cover the strategy but that would have gone nowhere near meeting the issue.
This investment has enabled the funding of 80 additional consultant posts, with support staff, in key areas such as medical oncology, radiology, palliative care, histopathology and haematology. Up to quite recently in many cities outside Dublin there were no oncologists. In the major urban centres there were no oncologists. Senator McCarthy spoke about how the people had to travel from west Cork. There was no oncologist in what was meant to be a super regional hospital, Cork University Hospital, up to two years ago. I was in Waterford last Friday where a third oncologist post will be approved shortly. Up to three years ago there were no oncologists in Waterford. This is all about care for women with breast and other forms of cancer.
I acknowledge the sincere commitment to try to expand the service. Let us acknowledge what has happened which represents a sea-change and a transformation in the quality of care for those with cancer. While we have a long way to go, we have achieved a significant amount. It is important to work collectively to get home the concept of combined modalities of care in centres of excellence. I accept Senator O'Meara's genuine concern about the issue of the mammography machine in Nenagh or Ennis but we have got to tell people that a comprehensive cancer programme is not light years away and is ahead of a mammography machine. Some still hold the view that if we have a mammography machine, we have a cancer service. We do not. Keeping in line with best international practice will give us the outcomes we desire and which we envy the capacity of countries such as the United States and others to achieve. This is emanating from people who have been abroad, worked in other centres and who have returned and want the best configuration of services, etc., for Ireland.
The most recent report of the National Cancer Registry, Cancer in Ireland 1994-1998 – Incidence, Mortality, Treatment and Survival, indicates that there is a significant upward trend in breast cancer incidence in women under 65 years. Importantly, there is also a downward trend in mortality rates in all age groups combined, reflecting the fact that survival from breast cancer is good. We are currently carrying out an evaluation of the national cancer strategy. The initial finding is that the original objective of reducing mortality rates is well on target. It is gratifying to see that because we would not like see services and facilities being provided if we were not getting some results in terms of better survival rates and reduced mortality rates. That is the key issue. These trends were evident prior to the initiation of the breast screening programme and I expect them to continue as a result of the continued improvements in treatments and also as a result of the national breast screening programme.
Breast cancer is the individual site specific cancer which has received the most investment in recent years. Since the implementation of the strategy, approval has been granted for an additional 39 consultant posts with a special interest in breast disease. That is a phenomenal increase by any standards in any specialty or area at consultant level.
All women with symptomatic breast disease should have prompt access to high quality multidisciplinary care. Although services should be delivered as close to the patient's home as is feasible, the overriding priority should be to provide the best, safest and most effective treatment for women and in so doing, provide the best opportunity for long-term survival to those who are found to have breast cancer.
The report of the subgroup on the development of services for symptomatic breast disease contains recommendations for the establishment of a network of specialist breast units throughout the country and the appropriate infrastructure, personnel and equipment needed for such specialist units. The report also makes recommendations regarding the siting of such units in each health board area.
The report recommends that specialist breast units should be based on a population of 250,000 to 300,000 from which it is expected that there will be a minimum of 100 new primary breast cancers per annum. The modern management of breast cancer entails triple assessment, a concept which those expert in the field constantly assert as being the key. It involves the surgeon, pathologist and radiologist working as an integrated team.
Since the publication of the O'Higgins report, my Department has been in consultation with the health boards in relation to the development of services for symptomatic breast disease in their respective regions. Since 2001 there has been a cumulative investment of approximately €30 million in these services. The benefit of this investment is reflected in the significant increase in activity which has occurred with in-patient breast cancer procedures increasing from 1,336 in 1997 to 1,839 in 2001. This is an increase of 37% nationally.
BreastCheck currently provides breast screening services to women in the 50 to 64 age group in the Eastern Regional Health Authority, North Eastern Health Board and Midland Health Board areas. It has proved extremely successful in identifying breast cancer among women in this age group and it also provides for the necessary surgical care of women who require breast surgery. To the end of November last year, the programme had invited over 100,000 eligible women for screening and screened nearly 80,000, with an uptake rate of 75%.
Since the pilot phase commenced in 1989, quality assurance has been an integral feature of the design and implementation of BreastCheck. An effective multidisciplinary structure is in place to advise on quality and ensure that it is sustained at the key interface with women presenting for screening or who require treatment.
BreastCheck has ensured that its programme is externally reviewed and validated. Last year a team from the European Reference Centre for Quality visited the programme. The key strengths of the programme identified by the reference centre are: outstandingly high levels of professional expertise; team working; and commitment to the programme with all disciplines working to an internationally recognised standard. The report also congratulates the programme on its investment in high quality and internationally recognised professional staff. This is high praise from an international visiting team and, at the launch of its annual report last October, I congratulated the board of BreastCheck and its staff, who have contributed at all levels to such an impressive result.
My commitment and that of my Department is evidenced by the significant funding that has been provided. There has been cumulative investment of €40 million to date in this programme. In addition, I have also made available approximately €6 million for the construction of a new state-of-the-art screening unit at St. Vincent's Hospital to replace the current Merrion unit. In 2000 we had problems getting enough radiographers and that slowed up phase one to a certain degree. We had to go overseas and do our own in-house education to try to increase the number of radiographers as quickly as possible for the service.
The board of BreastCheck has submitted a business plan and there are three geographic elements to the expansion in that plan. Three further counties – Carlow, Wexford and Kilkenny – are part of the eastern region. Women from those counties who require treatment will be referred to the static units in Dublin, which are already in place. In regard to the west and south, we have selected where the static units will go – the South Infirmary in Cork and UCH in Galway. We must build those static units before anything can happen in those counties. I recently announced that, as part of the next stage of the programme, BreastCheck will roll out the programme in Carlow, Wexford and Kilkenny. Approximately 19,000 women will be covered and about 60 additional cancers will be diagnosed.
I am fully committed to the further extension of the programme to the remaining counties in the west and the south. I will meet representatives of BreastCheck shortly in this regard. The objective is to prepare an effective and cohesive model which is in the best interest of the women concerned and which builds on the quality standards applied by BreastCheck and by the symptomatic services. Any woman with concerns, regardless of age, should attend her GP who will, where appropriate, refer her to the symptomatic services.
Senator O'Meara and others asked about the rollout and why we are meeting representatives of BreastCheck in advance. When I launched BreastCheck in 2000 I did not say it would be available throughout the country in two years. I know this because I re-read the speech I made in Dublin Castle on the evening in question. We said phase one would inform the rollout of phase two because it was very much a learning experience in terms of getting the external evaluation from Europe to make sure the quality assurance was right and so on.
When BreastCheck was launched in 2000 we did not have the Niall O'Higgins report on symptomatic services and the centres of excellence had not been developed. That is important for the following reason. It is the considered opinion of the BreastCheck board that we should roll out BreastCheck in accordance with phase one. Cork will be the static centre for the south and Galway for the west. We have funded and approved 13 centres of excellence and we believe there should be a synergy between the centres of excellence and the BreastCheck model. BreastCheck does not accept that, although it is prepared to discuss it with us and I am prepared to listen to the views of its representatives on this issue.
The practical implication of this is that we could roll out two different strands of a service. We would have 13 centres of excellence with teams of surgeons, radiologists and pathologists while the BreastCheck model would be in these areas as well with separate teams of surgeons and so on. There is an important issue here in terms of the rollout. If a woman from Letterkenny was attending the BreastCheck programme in the east, even though we had developed a centre of excellence in Letterkenny, would she have to travel to Dublin for surgery and for post-diagnostic care if she was diagnosed through breast screening? BreastCheck states that she would have to do so.
We are investing in centres of excellence in Limerick and Waterford, but BreastCheck has said that if women between the ages of 50 and 64 in those regions are identified in Cork, they will continue their treatment in Cork. We have, however, built centres of excellence and employed people in those regions. This is an issue we need to address before the service is rolled out. Funding will then be an issue, but we must resolve the matter to which I refer in the first instance.
Medical professionals have different perspectives on this. I will meet the BreastCheck board, particularly the medical people thereon, because I want to hear why they believe, despite the fact that we have centres of excellence, there should be a ring-fenced continuum in regard to BreastCheck. One would expect that the centres of excellence should be capable of doing some of the work and that those presenting would be given a choice. From BreastCheck's perspective, I can see that there is an issue of quality assurance involved and that it must see matters through to the end of the process. Most people looking at this objectively would say that if we have centres of excellence around the country and have provided significant funding and investment and recruited top class people, surely there should be some synergy between the two, particularly at the treatment phase. That is an issue which is up for discussion.
The cost is approximately €26 million over a two year period. It takes approximately two years to roll out a programme in terms of recruiting specialist staff for a multidisciplinary team and the building and equipping of units. The roll-out will happen on a phased basis in terms of the mobile units which must be put in place. This is a very exact and high quality service. The BreastCheck board received tremendous recognition and validation at a European level and is very anxious that the level of quality is maintained and continued.
The cervical screening programme is a valuable preventive health measure when delivered as an organised programme. Phase 1 commenced in the Mid-Western Health Board area in October 2000. Approximately 67,000 women in the 25 to 60 year age group will be screened at five yearly intervals free of charge. Funding allocated to the board to cover the annual cost of running phase 1 is in the region of almost €4 million. As part of an examination of the feasibility and implications of a roll-out of the national programme, the chief executive officers of the health boards are making arrangements to have an external review of phase 1 carried out during 2003. Other issues relating to the management of the national programme, in particular in the sphere of governance, are also being examined by them.
To meet the additional demand for cervical cytology laboratory services, additional resources have been made available in recent years to develop both laboratory and colposcopy services. These resources have resulted in the employment of additional staff, the purchase of new equipment and the introduction of new technology. In 2002 additional ongoing funding in the region of €2.5 million was provided. This year a further €1.4 million has been allocated to health boards for ongoing development of the services.
The developments I have outlined describe an overall framework through which cancer services can be developed and provided in the most co-ordinated and effective manner. I am pleased I had the opportunity to outline the substantial developments that have taken place in cancer services in respect of which we have made substantial progress across a broad range. We are evaluating the national cancer strategy with a view to formulating a new strategy for the next five years which the national cancer forum is undertaking in consultation with the Department. It is important to bring all services along together to make sure women who present with symptomatic breast cancer have as rapid access to quality of care as those involved in the screening programme. That is the reason we have put so much emphasis, particularly in the last two years, on investment in symptomatic breast cancer facilities and appointed the relevant consultants and so on.