I thank the committee for its invitation. We offer the apologies of our colleague, Professor Joe Ennis, the chief medical adviser to our board, who is unable to be here today because of an annual leave trip overseas. I am sure, however, he would be happy to come in on another occasion to answer questions the committee may have.
We have produced and circulated a briefing document, together with a copy of our first annual report, covering the period February 2000 to December 2001, and this presentation will answer the basic questions of what, why, who and how in the context of the BreastCheck programme, outline the programme's performance and explain how that factors in to the nature and scope of the proposed extension.
BreastCheck is an organised, population-based free screening programme for breast cancer which provides diagnosis and primary treatment to women in the age range from 50 to 64 in designated areas. In this context, the word "screening" relates more to the screening of the population rather than to the individual mammographic X-ray examination. Screening for breast cancer means the investigation of women who are apparently well and believe themselves to be free of serious breast disease and this is done to detect unrecognised breast cancer. Screening can be done on an opportunistic basis or through organised programmes such as BreastCheck and it is our belief that an organised programme is likely to deliver much wider benefit.
The relationship between a screening programme and a woman is fundamentally different from the relationship between a symptomatic patient and a medical practitioner. For this reason with a screening programme where women are invited for investigation there is an obligation to establish and maintain the highest possible standards at every stage in the process and failure to achieve excellence or to audit performance rigorously would damage and seriously undermine the effectiveness of the programme.
Why have a screening programme? Simply because international studies indicate that an organised screening programme could result in a reduction in mortality from breast cancer of 20% to 30% in the target age range, and currently in Ireland there are 650 deaths per annum from breast cancer. The primary aim of the BreastCheck programme is to reduce mortality from breast cancer. A direct relationship exists between diagnosis, satisfactory treatment and long-term outcome. A reduction in mortality cannot be achieved unless a diagnosis is followed by satisfactory treatment. It was on the basis of this rationale that the Department of Health and Children decided, prior to the commencement of the BreastCheck programme, that the programme would end not with the diagnosis of malignant disease but at the end of primary treatment.
BreastCheck is a specialist health agency established by statutory instrument. Its board consists of the chief executive officers of each of the health boards, including the ERHA and the three area boards. There are not more than four other members. They include, for example, Professor Niall O'Higgins and Ms Olivia O'Leary. The programme is staffed by world-class consultant clinicians of international standing and higher experienced radiographic and nursing personnel, with an essential office providing the necessary programme support and evaluation.
To answer the health question, delivery is achieved through central activities which include such things as a population register, the issuing of invitations, orchestration of public awareness campaigns and general support functions, including audit and evaluation, and through specialised static screening units which provide the mammographic service to women based on invitation. Each of the static units deploys multiple, mobile, mammographic units. There is an illustration of one of the mobile units on the front cover of the submission document. The static units provide centralised image reading, a multidisciplinary assessment and diagnostic team and associated facilities.
At the back of the presentation, in the appendix, we have detailed the roles of various members of the multidisciplinary team - radiologists, pathologists, surgeon and anaesthetist. In conjunction with a designated host hospital, the BreastCheck clinical team provides surgical admission and treatment, where required. In each case the BreastCheck unit functions back to back with the symptomatic unit of the host academic teaching hospital and BreastCheck's clinicians participate in the symptomatic units of the host hospitals.
The screening process is set out in diagramatic form on page four of the presentation which shows the various stages of interface between an individual woman and the screening programme from consent through invitation and appointment to the provision of a mammogram and from result through assessment, biopsy and hospital admission, where necessary. Once in the programme a woman would be invited to repeat this process on an approximate two year cycle while she remains within the age range. You will also notice on the flow process chart that each event has a time line associated with it. These are drawn from the BreastCheck Women's Charter, effectively our contract with our clients. This is set out on page six of the presentation. A slightly larger version is available on pages 12 and 13 of the annual report. The charter, together with EUREF standards, is used to benchmark programme performance. We have included a synopsis of programme performance measured against these standards at page five. That leads us to a brief discussion of the extension.
In the health strategy, many aspirations are expressed around the provision of our health services. BreastCheck has produced a model which is based on a transparent process, clear time lines and a women's charter. The programme is subject to rigorous QA processes and strict clinical audit. It is driven by international quality assurance criteria and best practice. In terms of clinical treatment the programme is not merely consultant led but is 100% consultant delivered. It is our view that BreastCheck provides a best practice model of the way health services should interface with clients.
On the basis of phase one performance, meeting or exceeding quality standards, there has been an uptake rate to date of 75%, detecting and treating 634 cancers to September 2002, in the first nine months of 2002 detecting an average of 30 cancers per month, representing a detection rate of 8.9 per thousand. On the basis of that, the board of BreastCheck submitted a business plan to the Department last July which proposed to roll-out the service in accordance with the existing model and to do so within two years of approval to commence. That plan is summarised on page seven. We propose enlargement of the eastern region - that was approved on Monday last - and the establishment of two further regions, western, based in Galway, and southern, based in Cork.
In breast cancer screening each discipline is required to achieve certain minimum activity levels. The size of our target population nationally, based on a two year screening cycle, means that four units can be sustained to maintain expertise and optimise outcomes. Any more than four units would be sub-optimal, leading to the service being compromised as against quality assurance standards. Equally, any less than four units would result in significant, avoidable and non-desirable logistical complexity. Members are aware that the southern and western expansions are awaiting approval and discussions are ongoing concerning this phase of the national roll-out. A key item for discussion is the appropriate linkages between the screening programme and the symptomatic services in those regions. Our board believes that potential synergies should be fully maximised, consistent with the objectives of BreastCheck and optimal outcomes.
Shared training facilities, common streams on broad QA issues and evaluation and data sharing methodologies fall within this category. As in the east, BreastCheck proposes that the two new screening units should operate back to back with the symptomatic units in the host hospitals. Our proposal, however, clearly supports the view that primary treatment should be offered through the screening unit by the multidisciplinary team, including surgeons with specialised training and expertise in the treatment of early screen detected breast cancers. This is as opposed to referral to one of the nine symptomatic units that will not be back to back with a BreastCheck unit. This approach is based on experience to date and key advice concerning the critical differences between symptomatic and screen detected breast cancers. In symptomatic mammography all women referred to a hospital have a palpable abnormality in their breast. These palpable abnormalities measure between two and four centimetres and can be visualised by a radiologist and removed by surgeons trained in the management of symptomatic breast disease.
Small cancers are the norm in screening mammography and large cancers are the norm in symptomatic mammography. The radiologist who detects the small abnormality must also be the radiologist who inserts a guide wire for the surgical localisation and removal of that small cancer. Complete removal of these small cancers can only be guaranteed when the surgeon to the screening programme and the radiologist who inserted the guide wire review the mammogram and are satisfied that the abnormality has been completely removed. Equally important is the role of the screening pathologist to ensure there is complete removal of the tumour by demonstrating that the margins are free of tumour tissue.
To manage these women appropriately and to guarantee internationally approved quality assurance standards, it is essential that only those consultants appointed to the screening programme - radiologists, pathologists and surgeons with expertise and a minimum caseload in screen detected cancers - are the consultants who will be responsible for the management of all aspects of screen detected cancers. All this leads BreastCheck to advise that existing policy should not be changed and should be uniformly applied to the whole country at an early date. That has been and continues to be the advice provided by the BreastCheck board. However, we recognise that there will be competing advice and ultimately this is a matter for the Minister. We believe the objectives of the screening programme, which have been met and exceeded by the first stage, would certainly be compromised by any change in how screen detected cancers are managed, that is to say we believe that the potential decrease in mortality to be achieved by the programme would be compromised.
