Seanad Éireann debate -
Wednesday, 16 Apr 2003

Vol. 172 No. 13

Cancer Treatment Services: Statements.

Minister of State at the Department of Health and Children (Mr. B. Lenihan)

I am pleased to have the opportunity to describe the extensive investment and reform programme which the Government has been promoting under the national cancer strategy, particularly since the launch of the health strategy in November 2001, and to set out the current position on cancer services nationally.

The Government is committed to the development of co-ordinated and patient-focused cancer treatment. The health strategy signifies the clear and high priority which my colleague, the Minister for Health and Children, Deputy Martin, attaches to cancer and cancer care as part of the overall health system. The first national goal of Better Health for Everyone contains a number of critical objectives on cancer care and significant progress has already been made on many of them.

An effective cancer care policy must be multi-faceted, broadly based and address the major influences which impact cancer incidence and mortality. The main elements of a cancer policy include health promotion, prevention, primary care and acute and palliative care services. All these services have benefited from investment and improvement.

Cancer is a major challenge to our health services. Approximately 21,000 new cases of cancer are recorded annually and one in three of our citizens will develop cancer in the course of their lifetime. Cancer is more common in older people and, as the population gets older, we can expect cancer cases to increase accordingly. The reduction since 1994 in cancer mortality rates is as a result of improved diagnosis, earlier interventions and improved and more widely available cancer treatments. It is expected that these trends will continue as a result of developments in cancer services and continued improvements in treatments.

Since the implementation of the national cancer strategy, a cumulative figure of €400 million has been invested in the development of cancer services. This level of investment is many times the increase of £25 million initially envisaged in 1996 to implement the national cancer strategy. The national cancer strategy acknowledges that the cause of most cancers is multifactorial, but that there is strong evidence that lifestyle factors, in particular smoking, alcohol and diet, play an important role. The promotion of healthy lifestyles is a key element of the work of the Department's health promotion unit and spending by the unit since the launch of the national cancer strategy on these topics is in excess of €17 million.

Under the Public Health (Tobacco) Act 2002, the Minister established the Office of Tobacco Control on a statutory basis. This indicates a commitment to a range of anti-smoking measures. In this regard, a ban on smoking in all workplaces from 1 January 2004 was announced. This ban will include the hospitality industry, where many workers are exposed to passive smoking.

For all health behaviours, there is a shortage of national data representative of the various social sub-groups in the Irish population. To combat this, the health promotion unit commissioned the national surveys of lifestyle, attitudes and nutrition, SLÁN. The first SLÁN survey was commissioned in 1998 to provide baseline information on a range of lifestyle-related health behaviours in the Irish adult population, with sufficient power to detect differences across age, gender and social strata.

In 2002, the health promotion unit re-commissioned the next phase of the national health and lifestyle surveys, with a larger population sample, which my colleague the Minister for Health and Children is currently launching. Some positive trends are emerging from this second survey. The top-line indications show that, across almost all demographic categories, smoking rates have fallen, but this trend has been most marked among girls and young women, a key target for our recent anti-smoking initiatives and an area of concern to us. The overall rate of smoking in schoolgoing children has fallen. While overall exposure to tobacco smoke is down, the rates of exposure at work and in licensed premises and clubs remain high.

Alcohol once again proved to be a problem, despite an increase in the number of school children reporting they had never consumed an alcoholic drink. One of the most positive findings in the second survey was the increase in adherence to the recommended consumption levels of fruit and vegetables in all social groups and in men, in particular.

There is increasing recognition internationally of the importance of primary care in the delivery of cancer care. The primary care strategy will provide us with the capacity to ensure that people can experience a well co-ordinated and integrated package of services appropriate to their needs in their own communities and in their homes. It will broaden focus of services to include health promotion, prevention and supportive care for those who have recovered from cancer, are living with cancer or are dying from cancer.

Investment to date under the national cancer strategy 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. The benefit of this investment is reflected in the significant increase in activity which has occurred. For example, the number of new patients per annum receiving radiotherapy treatment increased from 2,402 in 1994 to 3,809 in 2000. This means that an additional 1,407 patients were accessing these services, representing an increase of 58% nationally. The number of new patients per annum receiving chemotherapy treatment increased from 2,693 in 1994 to 3,519 in 2000, representing an increase of 30% nationally.

Breast cancer is the individual site-specific cancer which has received the most investment in recent years. Since the implementation of the national cancer strategy approval has been granted for an additional 39 consultant posts with a special interest in breast disease across the modalities of surgery, radiology and histopathology. Since 2001 there has been a cumulative investment of €30 million in the development of symptomatic breast disease 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, an increase of 37% nationally.

As the House is aware, the Minister for Health and Children, Deputy Martin, announced the national extension of BreastCheck, the national breast screening programme, on 27 March last. BreastCheck provides breast screening services for women in the 50 to 64 year age group in the Eastern Regional Health Authority, North-Eastern Health Board and Midland Health Board areas. This programme is proving extremely successful in identifying breast cancer among women in this age group and also provides for the necessary surgical care of women who require breast surgery. To the end of December last year, 110,636 eligible women had been called for screening and 83,000 had been screened, representing an uptake rate of 75%.

The BreastCheck clinical unit in the western area will be located at University College Hospital, Galway, with two associated mobile units. The area of coverage will be counties Galway, Sligo, Roscommon, Donegal, Mayo, Leitrim, Clare and north Tipperary. The BreastCheck clinical unit in the southern area will be located at South Infirmary-Victoria Hospital, with three associated mobile units. Counties covered include Cork, Kerry, Limerick, Waterford and south Tipperary.

Under the extension, approximately 130,000 women in the target population of 50 to 64 years of age will be eligible for screening. The programme expects to diagnose approximately 400 cancers per annum among this population. Under the business plan submitted by BreastCheck to the Department, the national expansion of the programme to the west and south has been costed at €27 million, including €13 million in capital costs. Discussions are ongoing involving officials at the Department, BreastCheck and relevant health agencies in relation to the detailed implementation of the programme.

In relation to the development of services for women with cancer, the commitment of the Government is further evidenced by the introduction of the cervical screening programme. Cervical screening is a valuable preventive health measure when delivered as an organised screening programme. To meet the additional demand for cervical cytology laboratory services, additional resources of €2.5 million were made available in 2002 and a further €1.4 million is being made available in 2003 to develop both the laboratory and colposcopy services.

An expert review group on radiotherapy services was established by the Minister to ensure we effectively plan the current and future development of this key element of cancer care. The current debate on radiotherapy services is very narrowly based and confined to geographic location without any real discussion of the principles that should underpin the national provision of services. International evidence is that radiotherapy is a service that can best be provided in a limited number of centres. It is certain that the future demands to provide a comprehensive service that is quality and equity driven will be extremely expensive. The objective will be to develop proposals on foot of the report that will provide us with a model of radiotherapy services that is patient centred, attracts and retains the best medical and scientific expertise, and ensures comprehensive radiotherapy treatments in a timely and quality manner.

I wish to advise the House of a number of developments in radiotherapy. In recent years significant investment in new radiotherapy services has taken place in Dublin, Cork and Galway. Some €25 million has been invested in the renovation and upgrading of St. Luke's Hospital, ensuring it continues to meet the demands placed upon it as a world class centre for the delivery of radiotherapy. Almost €9 million has been invested in phase one of a substantial new building project development at Cork University Hospital for radiation oncology services, which was completed in 2002. A new radiotherapy department is under construction at University College Hospital, Galway. This development is part of the phase two project at the hospital. In excess of €100 million has been allocated to this project which is due for completion this autumn.

The report of the national advisory committee on palliative care was approved by the Government in the summer of 2001 and launched in October of that year. The report describes a comprehensive palliative care service and acts as a blueprint for its development. The Government has agreed to the implementation of its recommendations over a five to seven year period. The implementation of the report will be undertaken as part of the implementation of the national health strategy. Since September 2001 almost €11 million has been allocated to the health boards and the Eastern Regional Health Authority to begin implementing the report's recommendations.

In February this year the first all-Ireland cancer network was launched under the auspices of the Ireland-Northern Ireland-National Cancer Institute cancer consortium. Its principal role will be to initiate and co-ordinate clinical trials in cancer hospitals in both parts of the island. The Department has demonstrated its support by investing significant resources in this trilateral programme. Under this scheme, awards to the value of €3.5 million have been made available to allow hospitals to recruit and train staff, improve facilities and take part in world class clinical trials. I express my gratitude to the United States' National Cancer Institute for this tremendously innovate research development and the interest it has taken in this jurisdiction as part of the peace process.

International evidence is that better clinical outcomes are achieved in hospitals with specialist staff, high volumes of activity and access to appropriate diagnostic and therapeutic facilities. I cannot stress that international evidence enough, in either this House or the Lower House. Best results in treatment are achieved where patients are treated by staff working as part of an integrated, multidisciplinary specialist team. This core principle must inform the current organisation of services and how we plan future services across the various modalities of cancer care.

I wish to refer to the work of the national cancer forum, a multidisciplinary group of experts appointed to advise on cancer services, including hospital services. The forum has advised the Minister that the current organisation of these services is not in line with international best practice. This is a very important message, one that every Member of the Oireachtas should transmit, although I have no doubt that many will refuse to do so. The forum will be reflecting further on this issue as it prepares the next cancer strategy, which the Minister expects to receive later this year.

International evidence is that technically challenging surgery, for example, can best be supported if it is concentrated in a relatively small number of centres. This is a message that is evidenced based and needs to be directed and pursued at a number of levels in our society. It must be understood that having a service is no longer sufficient; it must be a service organised in such a way that it is capable of delivering quality in line with international standards and practice. We must face the reality that we cannot continue to expect to be able to deliver the highest quality of cancer services across over 30 acute hospitals. Perhaps I am being somewhat cruel on the Seanad in saying so because it is in the Lower House that this particular issue comes to the fore even more.

As regards our achievements in improving cancer care, I have presented information to the House in terms of increased manpower and activity. This is an important measure of improvements in cancer care but we also need to develop further our understanding of the process of care. The ultimate objective in terms of the delivery of cancer care is that those in receipt of services experience outcomes on a par with best international standards.

Health information is fundamental to assessing and implementing quality programmes. The national health strategy has provided for the establishment of an independent health information and quality authority to lead the development of health information to support these requirements. The authority will exercise a pivotal role in relation to a number of key information functions. It is only through focusing on specific information developments such as this, to build on the excellent work of the National Cancer Registry, that we will be able to demonstrate continuously the positive impact that cancer services can have, and also identify the areas which may need to be addressed to strengthen further our cancer care system.

We are very fortunate that those involved in cancer care provide a professional and high standard of care that is appreciated by those with cancer and their families. I recognise their dedication and commitment. It is hoped the substantial investment is reflected in an improvement in health outcomes for cancer patients.

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 glad to have the opportunity to outline the substantial developments that have taken place in cancer services, to which the Government has demonstrated a consistent positive commitment. In recognising that a lot has been achieved I fully accept that more must be done. Cancer care is too important for us not to do so.

Mr. Feighan

I welcome the Minister of State. It is always good to see somebody who has strong roots in my county here. Roscommon people normally stick together.

Mr. Glynn

We will see.

Mr. Feighan

We will not be too hard on the Minister of State whose contribution I welcome. I also welcomed the announcement of a ban on smoking in all workplaces from 1 January next. The majority do not recognise the health problems smoking has caused here and elsewhere during the years. Passive smoking must be attacked at all times. It is welcome that people will not be permitted to smoke in pubs, restaurants and workplaces in the future.

When I had a pub, I worked behind the counter and very much enjoyed working there. It was an old-fashioned pub, a little like Doheny and Nesbitt's, only on a smaller scale.

Ms Feeney

There was plenty of money in it.

Mr. Feighan

Although I was never a smoker, I found my health deteriorating, which was one of the reasons I left the pub. After five years working there I knew that it was not the work that would kill me but the people who smoked. One could not tell people at the time that they could not smoke in a pub because we were told that it was part of the atmosphere and ambience. Therefore, I welcome the Government's attack on smoking in public places, bars and restaurants. One would not have the nerve to tell a customer to stop smoking. I genuinely believe that because I finished working in the pub at that time and I am no longer a passive smoker in such an environment I am much healthier.

Young girls are a key target of anti-smoking initiatives. Such initiatives which target young people must continue because it is considered modern for young people to smoke. I attended a conference recently and it is worth noting that since its introduction several hundred years ago more people have died from tobacco related illnesses, which include cancer, than in the Second World War. That was a stark message, which indicated that smoking and its effects had to be targeted.

Cancer is one of the most emotive issues. There are few people who have not been touched by the effects of the disease within their own or extended families. I want to deal with the issue in a sensitive and compassionate way. Hard questions must be asked of those whose responsibility it is to deal with and provide resources for best practice in this area.

There is a lack of radiotherapists. We are told to expect even higher rates of cancer in the years ahead with our ageing population and lifestyles which contribute to the disease. Even now we cannot claim to be taking adequate care of those who need the necessary supports. Every week more than 300 families are affected by a cancer diagnosis. Unfortunately, one in three will be diagnosed with cancer while one in four will die from it. Many of those diagnosed with cancer are unable to receive radiotherapy while those who can have to wait long periods – twice as long as recommended because of the shortage of radiotherapists. I undertook a study and found that only eight radiotherapy oncologists worked in the State compared to 12 in Belfast alone. That is the latest figure, which is unacceptable.

There was a problem in regard to the BreastCheck screening programme which the Government failed to extend effectively. This vital service was only available in three health board areas. I welcome the fact that it has now been extended. However, it must be provided throughout the country as soon as possible.

A new breast cancer diagnosis is made every five hours. According to the Irish Cancer Society, research indicates that Irish women have a one in 13 chance of developing the disease and a 10% lower survival rate than women in the United States. Screening can detect cancer 18 months before a lump appears. Therefore, the need to extend the screening programme is imperative. I hope the 13 breast units recommended in report of the national cancer forum will be implemented. I pay tribute to Deputy Cowley and all those who marched to secure this service. The death rate from breast cancer could be halved with better treatment.

An international cancer conference in Dublin was told by Professor John Reynolds, consultant surgeon at St. James's Hospital and professor of surgery at Trinity College, that gaps in the provision of radiotherapy were affecting individual patient outcomes. The position could be put much harsher. We were promised the report of an expert review group on radiography services in February 2002 and again in March 2003 but it has yet to be published. I would like it to be published as soon as possible. Professor Reynolds spoke of the need for more structured cancer clinics involving a multidisciplinary approach. With modern developments in communications between hospitals there are possibilities for co-ordinating their strengths.

One of the areas requiring urgent development is that of supportive care for cancer patients with improved co-ordination between health services. Great work is being done by the voluntary sector. I pay tribute to the hospice and the various agencies and voluntary organisations which put so much time, funding and expertise into helping cancer patients. In my area Mayo-Roscommon Hospice and North West Hospice have always been to the forefront. I know that their views are taken on board. This is a time to acknowledge the work they do.

Only last month it was suggested that the benefit of cancer treatment was being outweighed by the arduous journeys patients had to make to obtain it. It is an emotional time for patients and their having to travel a long distance to gain access to treatment does not help. A cancer specialist, Dr. Ian Fraser, talked of the huge commitments being made by patients to gain treatment. I am aware that one woman was away from her family for 500 hours. Dr. Fraser estimated that €36 million was spent by the South Eastern Health Board over ten years bringing patients to Dublin for treatment. This is unacceptable and cannot be best practice; it must be reviewed. These patients are removed from their families at a very difficult time when they most need support. Patients and their families must find somewhere to stay in Dublin, which causes great hardship. Dr. Fraser also expressed his dismay at the long-promised report into cancer and radiography services provision.

I complimented Deputy Cowley, who marched in Dublin to highlight these issues last month. Those who took part in that march are, like us, seeking a realistic budget for cancer care. However, the influence of the Minister for Finance is the problem. He has decided that finance comes before people's health. The Minister for Health and Children should be fighting more forcefully for extra funding. It is all very well to say that additional funds are not being provided because they are not being spent on the right resources, but the Minister for Health and Children should be fighting for extra funds for all parts of the health service, including cancer treatment services.

The ridiculous situation of Mr. Earley of the Mater Hospital and the Children's Hospital, Temple Street, was reported in yesterday's Irish Independent. Mr. Earley stated that he is available to perform surgery but that, due to cutbacks, his list of surgical appointments has been cancelled. He also stated that he is being asked to perform operations in the private sector under the Government treatment purchase fund. Comments were also made by the Beaumont Hospital accident and emergency consultant, Mr. Aidan Gleeson, on the implications of the possible closure of 115 beds in the Mater Hospital, at which between 20 to 30 patients are already on trolleys. In addition, there is a strike by public health doctors, who perform a crucial role in monitoring the spread of communicable diseases. With the ever-present danger of SARS on the horizon, all is not well in the health system.

If we are reducing the funding provided, how can we improve services in this vital area? I was informed confidentially that the budget for St. Luke's Hospital has been cut by €1 million this year. The hospital has coped to date with increased pressure on its services through extensive use of overtime and after-hours treatment. According to its annual report, however, the cutbacks mean that this cannot continue, although St. Luke's is seeking funds to install four radiotherapy treatment machines.

It is expected that the report will recommend that radiotherapy facilities be located in Dublin, Cork and Galway only. A major issue being highlighted is the concentration of treatment in areas of excellence – a matter to which I have already referred – but it is an enormous burden, in terms of the trauma and effort involved, on those who have to travel long distances for short but life-sustaining treatment. What one would expect as a right in a so-called advanced society is hardly just for those who are vulnerable.

The Minister of State said cancer services are a public health priority and that he would strive to ensure that those with cancer would get high quality, effective and evidence-based care. While he may point to the investment made in recent years and to the fact that the level of this investment has been sustained, it is fair to say that there is much to do to bring our health services up to a reasonable standard and to have proper, equitable cancer services.

The national cancer strategy 2003 is being developed by the national cancer forum in conjunction with the Department of Health and Children. On television last Monday night, comparisons were made between the number of neurologists in Ireland and the numbers in other countries. The results of these comparisons showed us to be in an unbelievably poor position. Why should Ireland lag so far behind? That contributes to the waiting lists and the incredibly lengthy periods patients must wait before seeing specialists. It was suggested that the waiting list for a neurologist is two years. If someone wishes to see a specialist, the situation is serious in the first instance and we hardly need to comment on the possibilities.

I wish the Minister of State well. This is a delicate area and I will give him any support I can to get to the bottom of this emotive issue. There are many problems in the health service, particularly in the area of cancer care. I compliment the Government on introducing a ban on smoking in public places. We need zero tolerance in this respect because tobacco has been a major health problem. We must do everything we can to ensure that young people, particularly young girls, do not find it as attractive to smoke as they once did and if we can do so this initiative will have succeeded.

I no longer work in the pub to which I referred earlier and I walk everywhere in my free time. I am not smoking and I feel a lot better. I hope we can impart our knowledge to those who are smoking.

Mr. Glynn

Tá fáilte roimh an Aire Stáit. Is ábhar an-tabhachtach atá le plé againn inniu.

Few conditions generate as much emotive debate as cancer, which impacts in an adverse way on every aspect of society. We have had the extension of BreastCheck, which is very important because it involves a very important section of our community, namely, women. I know far too many women – and men – who have gone to their eternal reward at a young age. Great trauma, distress and suffering is caused when a mother is taken, not just to her offspring but also to her spouse and extended family.

When we discuss cancer, we immediately think of men's health – an area which should be focused on. Despite discussing the matter with members of the medical profession, I do not know the reasons for the increased incidence of prostate cancer, whether it is an increase, per se, or the result of better diagnostic procedures. Questions are being asked about the PSA test.

The BreastCheck programme was recently extended and rightly so. It has been established that when cancer is detected in its primary stages there is a real chance to do something about it.

I support the Minister, Deputy Micheál Martin, in a total ban on smoking. That is the minimum any of us who have a sense of responsibility can do. Of course, we are told ad nauseam that people have a right to smoke, and that is true. However, not everyone else around them wants to smoke. With rights go obligations, and those who wish to smoke have a responsibility to those who do not.

There is statistical evidence available, as has been pointed out by Senator Feighan, to prove that environmental tobacco smoke has a very adverse effect on those who work in public houses. In the earlier part of my career I also spent a few years behind a bar, and, although I was a smoker at the time, on the morning after the night before – I was not a drinker then – I would feel the effects of working in a smoky environment. What is to be done? We strongly support what the Minister is advocating. To do anything less is like having a death wish, and I harbour no such feelings. I am sure that most Senators share that view.

Another area where our society has encountered great difficulty is among those working in the psychiatric services. People will say that Senator Glynn is on his old hobbyhorse again, being a former psychiatric nurse. As everyone who knows anything at all about psychiatry is aware, psychiatric patients have a long-established habit of tobacco use, or, as I should perhaps say, tobacco abuse, depending on how one views it. I must regretfully admit that far too many of my former colleagues went to their eternal reward at far too young an age. Many of the patients did so too.

I appreciate that the Opposition has a job to do. However, even the Opposition will have to acknowledge the great achievements that have been made. I would be the first to admit that we still have a long way to go. Perhaps that is one of the curses of being human. However, as far as can be achieved, the resources that have been put into improving cancer care, as must be acknowledged by all sides, have been extremely significant. In the past, the chances of surviving cancer were low and showed very little improvement from year to year. In recent decades, however, there have been some very important changes.

In childhood leukaemia, there has been a dramatic improvement in survival rates. Similar improvements have occurred with Hodgkins' disease, testicular cancer and melanoma. In many other cancers, improvements, though less dramatic, have nonetheless taken place. Now there is real hope – and, according to the saying, it springs eternal – for patients and families.

The Government is determined to ensure access to the services which have delivered this optimism for every person diagnosed with cancer. Effectively tackling the problem of cancer means achieving consistently high-quality specialist services for patients, their carers and their families. Everyone who knows anything at all about the treatment of cancer is aware that, just as with alcoholism, it is not merely the sufferer who is affected but the whole family. We must therefore be cognisant of the huge trauma in families where there is a cancer sufferer or sufferers. We must not merely talk about the treatment of the person unfortunate enough to have cancer. We must also consider the immediate and extended family.

The key goal of the 1996 national cancer strategy was to achieve a 50% decrease in cancer mortality in the under-65 age group in the ten-year period from 1994. That figure was achieved in 2001, three years ahead of target. At this stage – and I do not wish to be or sound flippant – much has been done, but we have a great deal more to do. Anyone who thinks differently is simply not in contact with the real world. We fully recognise the huge amount of work to be done.

The extension of the BreastCheck programme has been an extremely welcome development, as have the numbers diagnosed at an early stage. As has been pointed out – I repeat it only to underline it – where cancer is diagnosed early, especially at the primary stage, there is a real chance that something can be done about it. Those are not just my words, for it is an established fact.

The report of the subgroup of the National Cancer Forum on the development of services for symptomatic breast disease, known, of course, as the O'Higgins report, was published in March 2000 and contains recommendations for the establishment of a network of specialist breast units throughout the country. I am a member of the Midland Health Board, which I have the honour of chairing. It must be brought home to people that one cannot have a centre of excellence for cancer services in every county. That is the reality, and we must grow up about it.

Mr. Feighan

In every area, not in every county.

Mr. Glynn

We simply cannot have that, for, as anyone who knows anything at all about the treatment of cancer, including the treatment of symptomatic breast cancer, is aware, there must be a certain number of procedures per annum for them to be carried out safely. That is not rocket science, for every Tom, Dick and Harry knows that. When we talk about the extension of the BreastCheck programme, we must welcome what has taken place recently.

Mr. Feighan

The Senator can thank Deputy Cowley for that.

Ms O'Meara

That concerned many women.

Mr. Glynn

Senator Feighan should know that we do not merely talk about it – we do it.

Ms O'Meara

Forty-eight hours after the national march.

An Cathaoirleach

Senator Glynn, without interruption.

Mr. Glynn

People who came from doing nothing have to knock those who did something. The 1996 report from the Department of Health on cervical screening—

Ms O'Meara

They were pushed into it. That is why they did it.

Mr. Glynn

If the Senator listened, she might learn something. The 1996 report acknowledged that cervical screening is a worthwhile preventative health measure when delivered as an organised screening programme. Following the report's recommendations, phase one of the national cervical screening programme commenced in the Mid-Western Health Board in October 2000. A key concern regarding the development of phase one is ensuring a service underpinned by quality assurance and best practice. Under the programme, around 67,000 women in the 25-60 age group will be screened at five-yearly intervals free of charge. Around €3.9 million is allocated the board to cover the annual running costs of phase one.

The extension of planning and organising a national programme underpinned by quality assurance is a major undertaking with significant logistical and resource implications that requires very careful planning. The experience gained from phase one of the national programme should be of assistance in the context of implementing the commitment. As part of an examination of the feasibility and implementation of rolling out the national programme, the chief executive officers of the health boards are making arrangements to have an external review of phase one carried out during 2003.

Palliative care has rightly been mentioned. Following a Government commitment to develop a national palliative care plan, the then Minister for Health and Children established the national advisory committee on palliative care in summer 1999 with a view to preparing a report on the development of palliative care services in Ireland. The report of the national advisory committee on palliative care was approved by the Government in summer 2001 and launched by the Minister, Deputy Micheál Martin, on 4 October of that year. The report describes a comprehensive palliative care service and acts as a blueprint for its development.

Reference was made to radiotherapy services. We do not have a sufficient radiotherapy capacity to meet existing and future demands. The provision of radiotherapy requires significant medical, scientific and support expertise and resources, in addition to extensive capital investment. The Minister for Health and Children established an expert review group on radiotherapy services to ensure that we effectively plan the current and future development in this key area of cancer care. I look forward to the publication of this report, which I am sure will address the competing demands of quality and geographical location.

When we discuss the question of geographical services, we must consider it not only from the point of view of the State but also from that of the island as a whole. The Ireland-Northern Ireland NCI cancer consortium is a trilateral partnership involving the Department of Health and Children, the Department of Health, Social Services and Public Safety in Northern Ireland and the National Cancer Institute of the US Department of Health and Human Sciences. It was conceptualised by cancer physicians in Ireland, Northern Ireland and the United States who took their idea of a collaborative partnership to their respective Governments. The consortium was established in October 1999 on foot of a memorandum of understanding signed by the then Health Ministers of Ireland and Northern Ireland and the Secretary of State for the US Department of Health and Human Sciences. It seeks to bring together in a collaborative way the cancer treatment communities in all three jurisdictions with a view to enhancing the capacity of our cancer research and service delivery systems.

A great deal has been said about cutbacks. Any health delivery service that does not examine its operations on a ongoing basis, challenge its own decisions and ensure that value for money is obtained in the delivery of services, is not in touch with reality. Ireland is a small country and far too many of our citizens, young and old, are dying form the scourge of cancer. The application of resources must, therefore, be done in an organised and concerted manner to ensure that the optimal benefit accrues to those who suffer from cancer.

Dr. Henry

I welcome the Minister of State. This is an important issue because cancer and cardiovascular disease are the most common cause of death in the country. I am indebted to the National Cancer Registry which published, in March, the Cancer in Ireland Report 1994 to 1998. I commend all those who compiled it because it is a comprehensive and useful document.

The statistics contained in the report are, at times, cheering, but they are also a matter of concern. They point out that the survival rates, at five years, for non-melanoma skin cancer and even melanoma are quite high. In the case of non-melanoma cancers, every case should be cured and, mercifully, that appears to be the case. The good thing is that the lesion can be detected on the skin and the patient can bring it to the attention of their doctor at an early stage. Melanomas cause more of a problem, because they can spread rapidly early on. I was interested to see that in five years the survival rate in women was 85%, while that in men was 68%.

There are many aspects of the report that I would like a sociologist to examine. Was that difference in the survival rate due to the fact that men with skin lesions waited longer than women to have them seen to? Do we need to educate men about the essential fact of seeing a doctor as soon as they detect a skin lesion, particularly in view of the fact so many of these cases occur in people working out-of-doors and in the west? As we know, sunlight is a major contributor towards non-melanoma and melanoma skin cancer. We must consider the areas of the report to which I refer and examine whether further education is needed.

Lung cancer is one of the worst scourges. I support the Minister for Health and Children, Deputy Martin, in his desire to completely ban smoking in pubs and restaurants because of the awful risks to members of the public. On the Order of Business this morning, Senator Michael McCarthy raised the issue of a man who was stabbed to death in a New York pub because he objected to the fact that another inhabitant of the pub was smoking. The risk that Senator McCarthy, if he is a smoker, might die of lung cancer is far greater than that of his being stabbed to death in a pub – bad and all though the behaviour of people may be in such establishments, even those in Dublin.

I am concerned that the incidence of lung cancer among young women is decreasing to any great extent. This is an area that we need to tackle. A recent article in the New England Journal of Medicine stated that smoking is worse than sunlight in terms of the skin-ageing process. One can always identify heavy smokers, even if they gave up the habit many years before, when they come to visit one. It is known that the collagen within the skin thins dramatically in people who are smokers. We must emphasise this fact in the case of young women. When they are 18 years of age, they never think they will reach 50 years of age and that they will not want to look like a saddlebag for a camel when they do so.

It is on areas such as this that we need to focus in order to try to encourage people to stop smoking. We could be facing a situation where there will be an epidemic of lung cancer in women in their 40s and 50s. I also read an article which stated that in Tower Hamlets in London, for the first time ever a year or two ago, lung cancer beat breast cancer as the most common form of cancer in women. This is the first health board area in England where this has happened. I do not think it has happened in Ireland. Everything we can do about cancer and its prevention must be done.

The Minister for Health and Children should be applauded in his efforts to prohibit smoking. In Canada, where the prohibition on public smoking is in vogue in almost all the cities I visited, people had a good time in the pubs without smoking. They informed me that the bar trade had initially cut down slightly, but that the table trade, where people were eating, had gone up and this made up for it. I did not meet one member of staff in either Ottawa or Halifax who was not glad that the ban had been introduced. I hope the Minister for Health and Children persists with his intentions in respect of this area.

There are very good details given in the report about the influence of sex, age and stage of diagnosis on the likely outcome. Women appear to do better than men, in most instances, regarding survival rates. I am concerned about the situation regarding men with symptoms who may be less likely than women to go to doctors at an early stage. General practitioners will state that men are inclined to let things go that bit further than women before making a visit to the doctor. Bladder cancer is an exception. I do not know if women would not notice blood in the urine, which is the main sign of cancer, or do they put up with cystitis more readily than men might. All these issues need more investigation to ensure that people go early to their doctor.

People who are younger are likely to do better than older people in cancer treatments. We must take into account that older people may die from other conditions in the five year survival period. From the report, it appears that older people were not necessarily as aggressively treated with specific anti-cancer therapy as younger people. A 70 year old woman with breast cancer is as entitled to radiotherapy or chemotherapy as is a 50 year old woman. I realise that in cases where particular cancers have spread, people may decide that the treatment is too dreadful. A friend of mine who was undergoing chemotherapy recently, told me she could only describe it as horrific. It is not like that for every patient. However, everyone is entitled to decide what treatment they will undergo. Older people may, perhaps, be less likely to agree to aggressive treatment, but they must be offered it and we must ensure that ageism is not practised in respect of cancer treatment.

There is unfortunately a distinct problem regarding geographic spread as to where one is likely to receive treatment. In the west, for example, while people with breast cancer are undergoing more radical surgery, they are not receiving radiotherapy when it might be extremely important for the condition. That is a problem of distance from a radiotherapy unit. While we cannot have a radiotherapy unit at every corner, we need to have a better spread.

Stage of diagnosis was one of the most important points made in the report, with particular reference to the five year survival rate of those who had progressed to stage 4, where the cancer had spread to distant organs, for example, bone, the brain, liver or lung. Their survival rate was much lower than those diagnosed when the initial cancer was at a very early stage.

The type of cancer is important because cancer of the ovary unfortunately is inclined to be diagnosed quite late because people do not have symptoms until quite late and sometimes the symptoms are rather obscure. For example, I have frequently known cancer of the ovary to present as a deep vein thrombosis in the leg. While it accounts for only 3% of cancers in women, it accounts for 6% of deaths within five years.

We also know that there is a genetic basis in the case of both breast and ovarian cancer. It is not that common but we do have to try to pick out those groups most at risk of breast or bone cancer and the families in which they occur are entitled to screening. I have spoken several times in this House about the fact that the national centre for medical genetics in Our Lady's Hospital, Crumlin, which screens for breast cancer is squeezed for money. I do not know if it has run out of money but it undertook a pilot project which was incredibly successful following which it received another €80,000 to continue for a little longer and the last I heard was that it was going to have to let three of its technical staff go. If that happens, it means it simply will not be able to screen the blood samples taken from patients like this, which is really very bad, particularly in view of the fact that we now also know that the cancers which have a genetic predisposition require different treatment from those which do not and we certainly want patients to have the optimal treatment. Ovarian cancer presents a big problem regarding late diagnosis, as does cancer of the pancreas when, once again, late diagnosis leads to a much higher mortality rate. For example, in both men and women cancer of the pancreas accounts for only 2% of cancers but 5% of deaths.

Let me move on to breast screening. It is extraordinarily important that we provide for screening all over the country. I know the Minister for Health and Children has promised this but what does that mean? He has no money. It is the Minister for Finance who has to promise that there will be breast screening.

Senator Glynn talked about a prostate specific antigen and screening for prostate cancer which, combined with a clinical examination, does appear to be worthwhile. I must praise those involved within the construction industry who initiated a free screening programme for their members. This was useful, even in trying to get men to take a better interest in their own health. Such screening programmes are costly and have to be shown to be cost effective. I do not know if the incidence of prostate cancer or breast cancer is greater but, again, we have to look at environmental factors because both cancers occur in fatty tissue and there are constant worries about pesticides, herbicides and so on. In a country such as this we really must have ongoing research in these areas.

We cannot rely on the research of others. Why is breast cancer more common in the Po Valley than in the south of Italy, say in Sicily? There is a big difference in diet. In the Po Valley it is mainly dairy based whereas in Sicily it is based on olive oil. Could this have to do, for example, with the spreading over decades of various organophosphates, organochlorides and so on, which are taken up through the grass, eaten by cows and then consumed by us? We have got to be involved in research in these areas.

In another way delay in diagnosis is a problem which we and, particularly, the Minister of State and his Department have to address. There is a terrible delay in general practitioners getting appointments in hospitals with specialists in various disciplines. This is a very serious problem. Some hospitals, however, have managed to give priority slots, for example, in the case of symptomatic breast cancer. I think six Dublin hospitals now do this whereby every Thursday one has exactly what one would want. Patients are referred, seen during the preceding days and get immediate appointments. There are ten slots available. General practitioners are only to refer symptomatic cases and I gather are very good about doing this. The team meets on the Thursday and looks at mammograms, X-rays, blood test results, clinical reports and so forth. The surgeon, oncologist, radiotherapist and so forth then decide the best line of treatment for the person concerned. This is what we want. All round the country this will have to be tackled.

I know there are problems with the medical profession. I looked at the findings of another survey recently which indicated that some doctors were undertaking serious cancer surgery in only ten cases a year, a huge proportion which, perhaps 60%, involved breast and colono-rectal cancers, another very important problem. There are also problems, however, with local politicians who say women in their area should not have to travel that but if they have to travel 20 miles down the road to receive better treatment, surely to heavens they must be persuaded to do so. We cannot have the Taoiseach going to Castlebar and announcing that all will be well there, that they will get their own unit if there are not enough cases being dealt with. This is a very important matter.

When one hears of elective surgery being put off, as happens every day in our hospitals, frequently they are cancer cases. There are further delays due to problems with acute beds being blocked. Something has to be done about freeing these beds in order that patients will not be contacted by telephone in the morning and told their operations for breast cancer, stomach cancer, colono-rectal cancer are off because every day matters. It is totally unfair on them that this is happening. This is the area where we, as legislators, are important and have to ensure there are no delays. We have to educate patients to go rapidly to their general practitioners and the centre of excellent primary health care in general. First, however, we have to ensure they will get a rapid appointment with a suitable specialist and, when an operation is considered essential, will be brought into hospital without further delay and will receive the cancer specific treatment they need as rapidly as possible. I frequently meet people who have had either radiotherapy or chemotherapy put off for weeks because there was no bed available for them in the hospital.