JOINT COMMITTEE ON HEALTH AND CHILDREN díospóireacht -
Tuesday, 19 Oct 2010

Chairman

I welcome the delegation from the Irish Cancer Society which is becoming a frequent visitor. We like to hear the good news it has to report to us on a fairly regular basis.

Before I begin I wish to advise that by virtue of section 17(2)(l)of the Defamation Act 2009, witnesses are protected by absolute privilege in respect of their evidence to the committee. If witnesses are directed by the committee to cease giving evidence on a particular matter and they continue to do so, they are entitled thereafter only to a qualified privilege in respect of their evidence. Witnesses are directed that only evidence connected with the subject matter of these proceedings is to be given and they are asked to respect the parliamentary practice to the effect that, where possible, they should not criticise or make charges against any person or entity by name or in such a way as to make him or her identifiable.

The documentation received from the Irish Cancer Society has been circulated, as usual, to members. I invite the delegation to give a brief synopsis of it following which I will ask members for their questions.

Mr. John McCormack

I am happy to lead off. On behalf of the Irish Cancer Society I thank the joint committee for its invitation to speak on the important issue of cancer screening. The Irish Cancer Society has a clear commitment to promoting awareness and early detection of cancer. Screening programmes are a key part of the process of detecting cancer at the earliest possible stage, when survival rates are the best.

We have taken a lead role in calling for screening programmes and more recently making our commitment concrete when we took the innovative step of offering €1 million to the Government to ensure the roll-out of a national bowel cancer screening programme. Generally speaking, we are pleased so much progress has been made on screening programmes. The joint committee will speak later with the National Cancer Screening Service. I pay tribute to its work under the leadership of Mr. Tony O'Brien on the progress made on screening programmes. We look forward to more progress.

To briefly outline our running order for this presentation, Ms Joan Kelly, our nursing services manager, will speak in greater detail about our position on current screening programmes. Following that, Ms Kathleen O'Meara, head of advocacy and communications, will speak on our views on the bowel cancer screening programme which is due to be rolled out in 2012, and the work we have been doing to reduce waiting times for a colonoscopy, the most effective procedure for diagnosing bowel cancer.

Ms Joan Kelly

I thank the Chairman for the opportunity to address the joint committee. I will briefly discuss our position on the existing screening programmes and will then touch on our current position on prostate cancer screening.

We are delighted that CervicalCheck in its first two years of operation is finding high levels of uptake among women. We also strongly welcome the return of opportunistic smear taking since 1 September 2010, which means that a GP can take a smear from a patient without her having to wait for a specific invitation from CervicalCheck. This is particularly important for encouraging participation in the screening programme by traditionally hard-to-reach communities, who are at greater risk of developing the disease.

While we are aware that it is the Minister's intention to extend BreastCheck to women in the 65-69 age group, the current offering is in the 50-64 age group, this is subject to resources being made available. We are continually advocating for the Government to increase the age limit for breast screening in line with best international practice and European Council guidelines to 74 years of age. The National Cancer Screening Service now provides BreastCheck in every county in Ireland and has recommended to the Minister and the Department of Health and Children that the age limit be increased. The society advocates for the expansion of the screening limit, in the first instance to the 65-69 age group as mortality rates for this group are particularly high, and next to extend it to the upper age limit of 74 years.

The Irish Cancer Society is keeping a close eye on the emerging evidence and research and is very concerned at significant increases in the incidence of breast cancer in women under 50 years of age. We are absolutely committed to raising awareness, and early detection and population based screening programmes like BreastCheck and CervicalCheck are vitally important tools for detecting cancer at the earliest possible stage.

At present there is no screening programme in Ireland for prostate cancer. There has been much debate and research among health care workers about the possible benefits of such a screening programme. The difficulties around screening for prostate cancer occur because the prostate specific antigen, PSA, test is not specific in terms of diagnosis of prostate cancer. It can only indicate that a man may have a problem with his prostate gland which needs further investigation. Up to two thirds of men with a raised PSA do not have prostate cancer, therefore routine PSA testing of all men could lead to anxiety and unnecessary alarm.

We keep abreast of all available evidence on the potential effectiveness of introducing a national, population-based prostate cancer screening programme. Current evidence is insufficient to recommend a population-based screening programme because of concerns that it may not improve survival or quality of life and may ultimately cause more harm than good.

As research continues, we are learning more about the best way to detect prostate cancer and about the development of cancer itself. The Irish Cancer Society will continue to assess new evidence as it becomes available.

Ms Kathleen O’Meara

I am grateful for the opportunity to attend.

I will address the issue of bowel cancer screening and colonoscopy waiting times. We are speaking about the two issues together because they are linked. Bowel cancer is the second most common cause of cancer death in Ireland. In 2008, the NCRI reported more than 2,000 new cases and 966 deaths from the disease. More than 50% of patients in Ireland were diagnosed with stage three or stage four cancer. Stage four cancer is the most advanced stage of bowel cancer. Worryingly, fewer than 5% of patients with stage four bowel cancer survive longer than five years. It has been a priority for the Irish Cancer Society to press for bowel cancer screening. I refer to men and women between the ages of 50 and 74.

As part of our commitment to the screening programme, in July 2009 the Irish Cancer Society committed €1 million towards the roll-out of a national bowel cancer screening programme. It was a measure of our commitment and a mechanism to encourage the Government to roll out the very important programme. We are very pleased that the Minister did so in February this year. She announced a screening programme, to start in January 2012, for the 60 to 69 age group. This is a limited screening programme and we hope that it is the start of a programme rather than the end.

Dr. Alan Smith at the NCSS, from whom the committee will hear later this afternoon, is conducting a baseline study to review existing endoscopy services and capacity levels within the hospital system to assess which hospitals will provide screening colonoscopies when screening is rolled out. This is a big change from the existing screening programmes. The decision was taken to roll out the screening programme using the existing hospital services rather than construct a parallel system or separate dedicated centres. Separate dedicated centres would have been the original plan. Given the state of the national finances, the most effective and economic way of proceeding had to be found. Certainly, we have no issue with that. It is the way to go but we are concerned about having screening available in a hospital system that is already reporting an issue with colonoscopy waiting times.

The obvious question to ask is how hospitals that already have a problem delivering colonoscopies in the ordinary way can deliver an additional 6,000 colonoscopies when screening is rolled out. We understand that the NCSS is trying to use the advance work to prepare hospitals for screening to resolve the waiting times issue. We support this. We are seeking assurance that the problem of waiting times for colonoscopies will be solved in advance of the roll-out of screening; otherwise we would be concerned about the symptomatic service and we would be concerned about those ordinarily waiting for a colonoscopy. It is very important to emphasise that not everybody who needs a colonoscopy is being tested for cancer. While those in the 60 to 69 age group are those in the screening programme, many others will ordinarily need a colonoscopy.

Since November 2008, we have highlighted the issue of waiting times for colonoscopies. The number has gone up and down. When we started in November 2008, some 1,600 people were waiting longer than three months for a colonoscopy, while 900 were waiting longer than six months. Since then, on a bi-monthly basis we have highlighted the figures. In August, the number waiting for more than three months increased above 1,000. We are happy to note that the number for September 2010 had reduced to 705, representing a drop of nearly 35% on the preceding set of figures. This figure was reported in the past and is the lowest figure in the past two years for people waiting longer than three months. We are glad to see the trend appears to be going downwards. Unfortunately, however, the figure was not sustained in the past.

We hope the baseline study and the work being done between the NCSS and the hospital system, which includes every hospital in the country, will yield better processes and ensure that hospitals competing to be screening hospitals will have their game raised and deal with the waiting times issue.

The Irish Cancer Society is concerned that unless the problem of waiting lists is tackled in advance of screening being delivered, it will not be able to have full confidence in the ability of the hospital system to deliver a screening while not having an impact on services at the same time.

Chairman

I thank the delegates.

Deputy Jan O’Sullivan

I welcome the delegates and thank them for their presentation. I would like to ask them about the colorectal screening programme and progress thereon. I want to ask in particular about the capacity of hospitals. In some ways, the delegates have elaborated on this issue.

Given that 1,636 were waiting for longer than three months and 900 were waiting for more than six months, capacity is still a major issue. Have the delegates received any response in terms of outlining exactly what is planned in terms of capacity? Have the HSE and Minister indicated that they will address the issue of capacity in regard to the roll-out of the programme? This committee should take up this issue if there are doubts about it.

The programme is very important given the number who die of colorectal cancer. It is essential that symptomatic screening not be set back by the rolling out of the screening programme. It is this subject that requires our attention most at this point.

I received an answer to a parliamentary question on 6 October this year indicating that more than 700 women under 50 were diagnosed with breast cancer in 2008 and 2009. The next priority in terms of need concerns older women. I am interested in the delegates' views on whether it is effective to carry out screening on women under 50. Do they believe it should follow on as a further phase or is it more a question of awareness and self-examination? Is a screening programme appropriate for that age group?

Deputy James Reilly

I apologise for not being here at the outset. I welcome the Irish Cancer Society delegation.

The delegates presented their own figures. The HSE has waiting list figures, as does the NTPF. Perhaps the delegates will comment on the sets of figures, although they commented on them in their document to a certain extent. What is their position on other screening programmes such as that for high-risk populations or those with a possible hereditary risk? What is the society's position on screening for younger women, as referred to by Deputy O'Sullivan? I refer to BreastCheck.

What does the Irish Cancer Society say to men who inquire about PSA testing and who are worried about prostate cancer? What is the society's view on colonoscopies being performed in the community? A colonoscopy is an outpatient procedure and should be available in the new primary care centres as much as in the hospitals. If this were the case, it would certainly take the load off the hospitals and remove the risk of interference with the symptomatic patients and the number on the waiting list in that regard. The number has increased and decreased and one wonders whether it will increase again. I would be grateful for a response to my questions.

I compliment the Irish Cancer Society for the excellence of its work. The society has been very successful in creating awareness around cancer and at debunking the myths and reducing the fear of the diagnosis that people have when they hear those terrible words.

Senator Mary M. White

I concur with Deputy Reilly's remarks on the tremendous work of the Irish Cancer Society under the leadership of Mr. John McCormack and his staff. There is no doubt that the sense of fear has been alleviated and people feel they can be saved.

The gerontologist in Tallaght Hospital, Professor Des O'Neill, whom I have quoted on several occasions, states that women over the age of 64 years are seven times more likely to have breast cancer. I find there is a terrible denial of the human rights of older women. The incidence of cancer in older women is not on the radar. The Irish Cancer Society was innovative in contributing €1 million to the national bowel screening programme.

I will speak at 6.30 p.m. this evening in Trim, County Meath, on the issue of ageing and ageism. We stop calling women for breast cancer screening when they reach 64 years, the age that women are seven times more likely to get breast cancer. This is cruel, because not only are they not being asked to come for screening, they must take the initiative and arrange an appointment as a private patient. The cost of being checked out for breast cancer ranges from €130 to €250. Many are reluctant to make an appointment because they are afraid. In the North, people are called for screening up to the age of 70 years.

I spoke about positive aging in St. Augustine's Church in Drogheda and the denial of free breast cancer screening to women over 64 years was raised. This is a denial of the human rights of older women. I am not blaming the Irish Cancer Society but to be honest I am blaming the Minister. I am very disappointed at this glaring example of the denial of human rights. I believe the reason is that decisions are made at political and policy level in a male dominated environment, even though we have a female Minister. Why was screening stopped at 64 years? I will continue to keep making these points. I ask Mr. McCormack to consider how he could contribute to innovative ways to make this happen, as the older women of Ireland deserve this service.

Deputy Denis Naughten

I thank the Irish Cancer Society for its presentation. Senator Mary White is 100% correct in the point she makes but I wish to raise the issue of men's cancer. This is very much lower on the agenda in terms of investment, research, publicity and so on. The issue of cancers in the male population is not sexy. I have been following the issue of PSA testing. It seems that we are always one research project away from having an effective test. Is it the case that the level of investment in research is not sufficient to produce an effective test because the companies involved do not see a financial benefit in line with the screening for women's cancers? I would like to hear a comment on that.

I have a further question on Ms O'Meara's presentation, the delay in colonoscopies As the delegates may be aware, a delegation from the National Treatment Purchase Fund will appear before the committee. It makes the point that there is no need for a public patient to wait a long time for a colonoscopy. If that is the case why are people waiting months and months for these tests, if the capacity is in the system? The NTPF says it is not an issue and should not be an issue and yet we come across people who are on waiting lists for months to have a vital colonoscopy. A related question refers to the comment that the hospital system is struggling to cope with the existing demand for colonoscopies. We have a significantly frustrating situation in Roscommon, because the County Hospital in Roscommon was asked by Galway University Hospital to start carrying out colonoscopies to deal with the backlog they had. A special piece of equipment was required to do that and eventually after six months, it is now in place. Just when the equipment is in place, the hospital is down one theatre nurse, so the hospital does not have the staff complement to carry out the procedure in the hospital. It seems that when the hospitals are willing to carry out the procedures, they are being undermined when the basic resources are not being put in place. Roscommon County Hospital could genuinely deal with the backlog and process quite a number of patients over the period.

Deputy Charlie O’Connor

I join colleagues in welcoming the delegation. I will not single out Ms Kathleen O'Meara because this may embarrass her but we appreciate the help they provide to parliamentarians. It is important to have such presentations.

It is vital that we work through the issues of national importance. Mr. McCormack and I were in Tallaght on 13 September for the launch of the report on the bowel cancer screening programme, organised in the past two years by Professor Ó Moráin, who has also appeared before the committee. It is important that we support that type of initiative. I have certainly called for a second phase of the pilot programme to be funded by the Department. The statistics show that the screening programme was very successful and several people were literally saved by the initiative in the sense that they might not otherwise have been brought to the attention of the medical experts. It is time we understood that these types of programmes are important. It is not just about Tallaght but other colleagues have mentioned their towns. Bowel cancer screening should be replicated throughout the country. I have no hesitation in saying that. The initiative on men's health was publicised by my good friends Niall and Gillian Quinn. I agree with my colleague, Deputy Naughten that it is important that we deal with health issues relating to men. I am no different from any other man, but a health scare 11 years ago gave me a different perspective on how to deal with health. Before that I probably did not bother about health all that much. We need to promote a positive message on screening — Senator Mary White would want me to say not only among men but throughout society.

It is important to support the work of the Irish Cancer Society.

Deputy Margaret Conlon

I too welcome the representatives from the Irish Cancer Society and join in complimenting it on its excellent work. The society has had many positive outcomes and it is good to see that. On screening for breast cancer, it is important that the age limit be extended, because of evidence that as people get older, the incidence is higher. When a person does not get a reminder to go for a breast check examination, she may not bother, thinking she is out of the danger period.

On the whole issue of health promotion for men and women, but particularly for men, none of us likes going to the doctor or the hospital but one goes when one has to. Sometimes men find it very difficult to go and, perhaps, wait until it is too late. It is important to promote the message and highlight the need to have the simple checks done. I made the point recently that if one was driving a car that had some mileage up on it, it would have to undergo an NCT so why not look after oneself given all the miles we cover. When people have a raised PSA they think there is a serious problem and it causes unnecessary worry and anxiety. There are other issues to be taken into account. I am sure the research has focused on diet, exercise and lifestyle choices which are all part and parcel of it.

I am concerned about colonoscopy waiting times particularly given that we have been told capacity is available. It is important these tests are carried out and that people are not left waiting for long periods. There is evidence to show that of patients with stage 4 bowel cancer, less than 5% survive longer than five years. That is very scary. If people are waiting for a colonoscopy for a long period all these thoughts go through their minds. A positive outlook and a positive attitude certainly aids recovery.

Chairman

There is a vote in the Seanad.

Senator Geraldine Feeney

I welcome the delegation. The whole area of cancer screening is a very positive story. It makes us conclude that screening is the way to go. I thank God the Irish Cancer Society is there to keep a watchful eye over it.

In regard to colonoscopies, I am aware of a process within the HSE of identifying screening centres. Having listened to Ms Kathleen O'Meara speak on the waiting list and the backlog, is there a list of the hospitals being considered and the waiting lists in those hospitals? Thankfully most cancers are curable provided they are detected on time. In regard to prostate cancer, the PSA is the only indicator at present but it gives rise to great concern among people because they think it is lights out for them. Has any research been done on another method of detecting prostate cancer rather than the one that we know of which is not reliable in many cases?

Deputy Rory O’Hanlon

It is important to recognise the tremendous improvements that have taken place in recent years in the whole management of cancer, particularly the national cancer strategy. I compliment the Irish Cancer Society for the excellent work it has done over many years. Today it is highlighting the importance of screening. I agree with the points raised concerning the difficulties with, for example, prostate cancer screening and the need to expand the age profile for the other cancers we have discussed. Prevention is far and away the most important contribution any of us can make to the health of the population. Side by side with the screening programmes, we must always highlight the place of tobacco. While the campaigns over many years succeeded in reducing the use of tobacco to a certain level, I am disappointed we could not reduce it any further. This is something we have to work on together. Diet is also important.

What are the priorities in regard to screening? What can be done to get greater efficiency into the cancer screening programme? Ms O'Meara raised concerns about cancer screening facilities that may or may not be available in general hospitals. There has been a major reconfiguration of hospitals in recent years, particularly a number of the smaller hospitals where the acute services have been transferred to larger, more state-of-the-art centres. There is a capacity there that is being used in some instances for screening.

Deputy Beverley Flynn

I welcome the Irish Cancer Society and thank it for its good work, particularly its appointment of a nurse to deal with after-care for women who have suffered breast cancer and to give advice on prostheses. That is a welcome development. We appreciated the briefing session from the Irish Cancer Society earlier in the year on that issue.

We have witnessed major developments in recent years. Three or four years ago many of these cancer screening programmes had not started. It is important to acknowledge that. However, I echo the concerns raised by my colleague, Senator Mary White, in regard to the screening of women over the age of 64. One in ten women in that age category is at risk of getting breast cancer and one in nine of those over the age of 70. Those are frightening statistics. As far as I am concerned it is a priority that there is an advance in that particular screening programme. Given that this is a time of limited resources, if the Irish Cancer Society had to prioritise the projects it has identified today what would be its order of priority? While everything is important, I would appreciate it if it could outline such a priority list.

Given the high level of uptake of CervicalCheck, in percentage terms what is a high level? In regard to colonoscopies I understand the numbers on the waiting lists are frightening. I presume the figures are an average across all hospitals and that some hospitals are better than others. In terms of the colorectal screening programme, let us hope the hospitals that are identified as the selected hospitals for the screening will be the hospitals that have capacity and the better statistics.

Deputy Niall Blaney

I welcome the Irish Cancer Society. It is only right that we recognise the fact that cancer diagnosis and treatment have improved considerably in recent years. We must also recognise the very important role the Irish Cancer Society has played in bringing that about and I hope it continues in that vein. I am a little concerned, as are Deputy Conlon and Deputy Naughten, in regard to prostate cancer screening. From the point of view of the health care professions and the presentation today, a general view is taken about prostate cancer screening. The relevant part of the presentation states: "Current evidence is insufficient to recommend a population based screening programme because of concerns that it may not improve survival or quality of life and may ultimately cause more harm than good."

I feel that is generally the opinion taken about men's health. Maybe that is partly because we are more to blame in that regard than anybody else. If that form of reply was given in the context of breast care it would not be accepted anywhere. Our approach to men's health, including prostate cancer, is not as it should be. Although issues arise in respect of the PSA test, it must be borne in mind that if a man's PSA is raised it is not without reason, as there must be some underlying health condition. If we introduced the system proposed, it would not be a waste of time and effort. However, we need to change the way in which we consider male mental health issues and, in this instance, prostate cancer screening. There is not enough emphasis on the latter. We are not putting enough resources into research. We need to be more careful about how we approach men's health, prostate cancer screening and information provision. We would not treat other cancers in the same way as we treat prostate cancer.

Deputy Bobby Aylward

Like everyone else, I compliment the Irish Cancer Society on its efforts. The old adage that prevention is better than cure is the one we are all considering, particularly in respect of cancer. I compliment the delegates on their offer of €1 million towards the roll-out of a national bowel screening programme. It is a great offer and it demonstrates the work of the society.

I am from Kilkenny in the south east and am therefore familiar with the Susie Long affair and the publicity over waiting lists. That 1,636 people were waiting more than three months in 2008, and 900 more than six months, means there has been an improvement.

The hospital system is struggling to cope. Does the Irish Cancer Society envisage that the centres of excellence or general acute hospitals will roll out the screening programme? What is the mechanism for working this out and what are the personnel requirements? When the programme is rolled out, how will it work out and how long will it take to start screening?

Deputy Kathleen Lynch

I welcome the delegation and compliment it on its years of work. At least we are now seeing some of it come to fruition. There will always be other matters to tackle but, nevertheless, from time to time highlighting issues really works.

The society is very conscious of the continuous fight we put up in Cork regarding the breast screening service and its transfer from the South Infirmary-Victoria University Hospital to the new breast care unit in Cork University Hospital. Guarantees and assurances were given in this regard. The breast unit in South Infirmary-Victoria University Hospital was a centre of excellence and ticked all the boxes.

The drive to centralise all services onto one campus was the reason the unit was moved to Cork University Hospital. The decision had nothing to do with excellence and was about centralising the service. When centralisation occurs, as in this case, does the society receive any follow-up information on whether it is successful? We received many reassurances in Cork that beds would be ring fenced and that there would be no waiting times for people already diagnosed or those who had a relapse after treatment, thus exempting them from having to queue up again in the accident and emergency unit.

One should consider the cases of those referred by BreastCheck, by general practitioners, those who refer themselves, those who are well but still worry, and those who have cause to worry. Our information is that numbers are now such that people are being sent back to the South Infirmary-Victoria University Hospital. Having a split campus worries me. Does the Irish Cancer Society receive any information on that or is it entitled to that type of information? Does it make further inquiries into such matters?

Deputy Dan Neville

I welcome the delegation. I apologise for my absence during the presentation but I saw it on the monitor.

Questions have been asked and I do not want to repeat them. I work a lot with the mental health services. The Irish Cancer Society has succeeded in destigmatising cancer. That is one of its main successes. By destigmatising cancer, it has drawn the attention of the political system to the needs that arise. This was done in respect of tuberculosis by Dr. Noel Browne during the term of the inter-party Government. We want to achieve this in respect of mental health services. We do not know how we will do so. The Irish Cancer Society has been very successful because it has got rid of the term "big C". We never hear this any more and people now refer to "cancer of the throat", "cancer of the lungs" or "cancer of the skin". To assist my work, I would like to know the Irish Cancer Society's formula for destigmatising cancer. This knowledge would be of enormous benefit to us.

Deputy Caoimhghín Ó Caoláin

I join my colleagues in extending a sincere welcome to the representatives of the Irish Cancer Society. I have two very brief questions. Regarding the significant number of letters sent to women inviting them to be screened for cervical cancer that have been wrongly addressed and returned, is the Irish Cancer Society satisfied this matter has been addressed satisfactorily? Is the Irish Cancer Society aware of specific steps that have been taken to ensure the problem will not recur? I have learned from women to whom I have spoken. They have advised me that they know of others who were contacted by their general practitioners to discuss their test results but who did not receive what they understood they had a right to, namely, simultaneous direct notification from the screening service. Could the Irish Cancer Society clarify the position on this? Is the women's experience common? Am I wrong in my understanding that there was to have been simultaneous issuance of test results to the women and their general practitioners? I thank the delegates once again for attending.

Chairman

As members have said, the Irish Cancer Society is a very effective organisation. Perhaps it is a victim of its own success because every member has had something to say about its work, and all the comments have been complimentary.

One of the key points the delegates are making concerns the problem with waiting lists. I suggested in the House last week or the week before that there is an amazing amount of investment in scanning and scoping equipment for private health clinics across the country. Some of this equipment is of a higher standard than that available in some of our public hospitals. We will soon be meeting representatives from the National Treatment Purchase Fund. Should we be advocating strongly a similar investment in capacity in order to reduce waiting lists? The Irish Cancer Society expresses some scepticism about the capacity of the hospital system to reduce waiting lists in an appropriate time. Does it see merit in adopting the approach to which I refer?

I ask the delegates to be succinct. We are under pressure for time as two other groups are to appear before us. If there are points the delegates cannot deal with adequately in their response, they may address them in correspondence later.

Ms Kathleen O’Meara

I thank the Chairman. I will begin with his question because it relates to a number of questions asked by Deputies O'Sullivan, Reilly and Naughten and Senator Feeney and others on the issues of bowel cancer screening, capacity and waiting times. I will take all those questions together. Deputy Reilly asked about the difference between HSE and NTPF figures.

With regard to the issue of capacity, representatives of the National Cancer Screening Service, which is part of the HSE, will be here this afternoon. Much work is being done at present to ensure that all hospitals will be ready for screening. Our understanding is that between eight and 12 hospitals, geographically spread, will be chosen as the screening hospitals. They will not necessarily be the larger hospitals, but they must show they have the ability to deliver screening colonoscopies without affecting the symptomatic colonoscopy services. This is what we want to see happen. Studies were completed recently and the hospitals in question still have a year to bring their services to the level and standard required to be screening hospitals. We see this as a great opportunity to improve the service across the country. Obviously, there will be cases where hospitals, not through their own fault, will need some investment, whether infrastructure or staffing. While we cannot say how that will be managed, I understand it must be incorporated into the necessary investment. As I mentioned earlier, this screening programme is very different to other ones, such as BreastCheck. In other words, the delivery of the screening service within the hospital system was not part of the original thinking. However, given the current economic situation, this is the way forward. We understand there is a high level of confidence it can be done and that the waiting times issue can be resolved in the process. We look forward to that and want to see it happen.

Deputy Reilly asked about the NTPF and HSE figures. In January of last year, the Minister directed the HSE that patients waiting for an urgent colonoscopy should be seen within four weeks and the HSE's figures indicate that very few people wait longer than four weeks for an urgent colonoscopy. However, we do not know what the guideline is for so-called "urgent" colonoscopy and our concern is that many people in the non-urgent group have cancer. Deputy O'Connor referred to the Tallaght study carried out by Professor Ó Móráin, which shows clearly that people with no symptoms who took part in that pilot screening programme had cancer. We are concerned, therefore, that not only urgent cases, but non-urgent cases are seen as soon as possible.

The issue of capacity has been raised by more than one member of the committee. The NTPF has said that the capacity exists within the public and the private system to deal with all the people on waiting lists. Why, therefore, are they not being seen? We have been scratching our heads on this, but short of asking everybody on the waiting lists why he or she did not respond to the letters they received from the NTPF to be referred to a private hospital for a colonoscopy, we cannot give an answer on that. However, we are sure there are a range of answers to that question. The NTPF has its view on the issue also. One reason may be that people do not want to travel half way across the country for a colonoscopy. Another reason might be that they are familiar with the team in a particular hospital and do not want to have to see another team. The fact is, there is enough capacity in the system to ensure that everybody who has been waiting longer than three months can be seen straight away. Therefore, the issue must be to do with how the service is organised.

We do not know what the outcome will be but understand that all hospitals are being considered as screening hospitals. As most members are aware, I am from Tipperary. I was in Nenagh Hospital on Saturday attending an exhibition and am aware that the hospital wants to be a screening hospital and has invested in an endoscopy suite. This is replicated throughout the country. There is a level of competition to acquire the screening service and we consider that a good thing.

I will hand over to my colleagues now, Ms Joan Kelly and Ms Naomi Fitzgibbon. Ms Kelly will deal with issues relating to prostate cancer. We want to talk about the issue of men's health before we finish because the issue has been raised by several members.

Deputy James Reilly

May I ask the Senator that was, sitting beside the Deputy to be, what her view is on colonoscopies being carried out in primary care centres?

Ms Kathleen O’Meara

I will let Ms Kelly address that.

Ms Joan Kelly

A full colonoscopy is quite an invasive procedure as opposed to a flexible sigmoidoscopy, which does not see the same extent of the bowel. It is important the test is done to the highest possible standard. There may be a time when we can do it in primary care centres, but the baseline study the cancer screening service is considering is looking at the many regional hospitals around the country, which would mean that people would not have far to travel for their colonoscopies. The role of the primary care centres is an emerging one and it is an interesting idea to consider whether the test can be provided in such centres in the future.

With regard to screening programmes for other high risk cancers and cancers with a genetic predisposition, two common cancers have a genetic link, namely, breast cancer and colorectal cancer or cancer of the bowel. Both of these cancers have a family and high genetic risk that is passed on through the family. Therefore, we in the Irish Cancer Society are particularly conscious of the need for proper screening of these patients, through the existing symptomatic services or hospitals. A group from the National Cancer Screening Service has carried out a study on this and a report was sent to the Minister earlier this year on the development of high risk screening services for people with a family risk of developing a cancer such as breast or bowel cancer. In addition, emerging research shows that lung cancer is another area where there are benefits from early detection. Emerging research shows that the use of spiral CT scanning of people at a high risk of lung cancer who have a history of smoking or who are current smokers can result in early detection and produce good results in terms of diminishing mortality in this group. This is at research stage currently, but we are keeping an eye on it.

The question of the PSA test was raised and frustration was expressed with regard to detection of prostate cancer through a national screening programme. In many ways, in a screening programme the bar is raised higher than it is in the general health environment. It is the "do no harm" approach. It is important that people are not brought into a screening test that will cause them to worry unduly and test them for something that would not affect their life expectancy in any event. It is frustrating that the research on prostate cancer detection is where it is and we have concerns about that. The Irish Cancer Society is the largest voluntary funder of cancer research in Ireland and it has invested €3 million in prostate cancer research since 1990. In particular, we funded a prostate cancer research consortium which brought scientists, doctors, clinicians and researchers from institutions, universities and hospitals and so on together to get the best brains and talent working on the problem. This has been a success.

We continue to keep a close eye on the area of prostate screening. This screening does not just involve the PSA test but involves a clinical examination, a digital rectal examination and a biopsy. The problem is not so much to do with the failings of the PSA test in itself, but with the natural history of prostate cancer in that it can be very indolent. It is common that men who have prostate cancer do not die from prostate cancer. What continues to be the most difficult and frustrating aspect is that it is hard to determine who will die from prostate cancer once it has been diagnosed and who will not. Two of the important treatments for prostate cancer, both radical prostatectomy and radiation therapy, carry significant morbidity of erectile dysfunction and urinary incontinence. Both treatments are not without difficulties.

Deputy Denis Naughten

What level of funding would have been invested in research on breast or cervical cancer in that 20 year period?

Ms Joan Kelly

Screening for cervical cancer has been available for a long time and we were late to provide it in Ireland.

Deputy Denis Naughten

Is it the case that funding is not going into research on prostate cancer because it is not seen to be as lucrative an area as the yield from research into women's cancers. Ms Kelly stated that in the past 20 years the Irish Cancer Society has invested €3 million in research on prostate cancer but how does that compare with the scale of investment in research into cancers that affect women during that time?

Mr. John McCormack

When it comes to prostate cancer screening, no country has introduced population based prostate cancer screening for the simple reason that the PSA test is a blunt instrument. Many men die with prostate cancer rather than from prostate cancer and the idea of subjecting every man over the age of 50 years to that test is just not tenable. The Deputy is correct that we need a smarter test and the Irish Cancer Society, as Ms Kelly alluded to, is funding millions of euros to try to find a smarter test. It does not necessarily mean that the smarter test will be found in Ireland but when it is found, wherever that may be, we will be in the best position to take advantage of it because of the work we are doing in the area. Funding for prostate cancer research is harder to find than for breast cancer research. The reason for that is that women have gone out and lobbied and marched to great effect for funding for breast cancer research. One cannot compare the test for breast cancer with the test for prostate cancer. Mammography for breast cancer is much more accurate and specific than the test for prostate cancer.

The good news is that now we have rapid access prostate cancer clinics. There is one in Galway, one in Dublin and at least four others are planned. When men present to their GP with signs and symptoms of prostate cancer they will be fast tracked to these rapid access prostate cancer clinics. I know for a fact that the clinic in Galway is, if I may use the phrase, "out the door" with work. There is good news is spite of the fact that the underlying test we have is not great.

Deputy Denis Naughten

What is the ratio of research funding into men's and women's cancer?

Mr. John McCormack

Research funding for women's cancer is a multiple of that for prostate cancer, but it is improving.

Chairman

Does Deputy Reilly wish to comment?

Deputy James Reilly

I wanted also the comparison of the research spend, the question asked by Deputy Naughten.

Chairman

Are there any concluding remarks?

Ms Naomi Fitzgibbon

Questions were asked about breast cancer screening for younger women. We have been looking into the research findings. In 2008, 2,815 women were diagnosed with breast cancer compared to 2,490 in 2007. When we examined the age breakdown, it is clear there is a bulge in the incidence of cancer in the 50 - 59 age cohort and that is followed by a high incidence in the 60 to 69 cohort and then that is followed by a higher incidence in the 40 - 49 age cohort.

Deputy Kathleen Lynch

Is the bulge in the 50 - 59 age cohort apparent as a result of screening?

Ms Naomi Fitzgibbon

It would result from awareness and the screening programme. We have examined this breakdown further. We looked at what was happening in the 40 to 49 age group. There were 455 cases in 2007 and of these 176 were in the age group 40 to 44 and 279 were in the age group 45 to 49. In 2007, there were 227 cases diagnosed in the women who were in the age group of 65 to 69 years. We are very conscious of the increase in the number of women in the younger age group but we want to extend the age group to those in the 60 to 69 age cohort.

In relation to older women, the message on breast awareness is to remind older women who are not in the screen age cohort that they must continue to be breast aware and to continue to report any changes to their GP so that they will get into the symptomatic service. We have worked with BreastCheck in the past, so that the final letter women get at the age of 64 years has a phrase that women must continue to be breast aware and report any changes. We are working very hard and we hope the National Cancer Screening Programme will extend the age limit to 64 years, where there is still an increase in the incidence of breast cancer.

Mr. John McCormack

We were asked about our priorities. There is no doubt that our priority is bowel cancer screening. It is urgent and there must be no slippage in the Minister's commitment to rolling this out by 1 January 2012. We will start to save lives within two years of the introduction of that screening and the service will pay for itself in a five year period because of the costs of treating advanced bowel cancer. That is our number one commitment.

We support a pragmatic use of private resources. In the region of 50% of the population has private health insurance. There is no doubt that private sector resources should be made available. Deputy Neville raised the question of stigma. The Irish Cancer Society has managed to deal with stigma by working with men and women who have been through a cancer journey and who look so well, people who have had the benefit of the level of resources that we now have in Ireland, that is very good cancer doctors and nurses, and who have come through the other side. They have featured in newspaper articles, and are working alongside us. That is crucial. There are so many more people beating cancer here. They are heroes and we in the Irish Cancer Society love working with them.

We are delighted to see the focus today on men's cancers. That is important. We ran an advertisement with Charlie Bird about getting men to be aware of the PSA test and we will continue that work. There is no doubt that we will do what we can on extending the age cohort for national breast cancer screening.

I thank the chairman for inviting us to appear before the joint committee. It has been a very useful exchange of information.

Chairman

I thank Mr. McCormack and his team for their presentation and for dealing so comprehensively with the questions. If at any time the joint committee can be of assistance to the Irish Cancer Society, we are ad idem on supporting it.

Sitting suspended at 4.28 p.m. and resumed at 4.31 p.m.