Seanad Éireann - Volume 118 - 21 January, 1988

Adjournment Matter. - Cancer Testing Facilities.

Mrs. Fennell: I would like to thank you first of all for enabling me to raise this matter on the Adjournment and I thank the Minister of State for being here. I raise this matter for a number of reasons. We are talking of course about the programme or lack of programme for cervical smear testing and for breast examination for cancer in this country. I raise the matter because I am very concerned that there has been a decrease in the number of outlets where cervical smear testing can be done. This is a service which will suffer very badly and is suffering because of the health cutbacks. I raise it also because in the last Administration when I was Minister of State responsible for women's affairs I [832] realised that this service for women was one that required constant pressure. I say to the Minister and to his Department that I found a very haphazard and patchy approach to this service. Unless women's organisations or the Congress of Trade Unions or my office were constantly harassing the Department things fell by the wayside. The cytology section in St. Luke's Hospital tended to have a terrible backlog of test results and it was very unsatisfactory.

The Department responsible for women's affairs are no longer there. We are suffering health cutbacks and despite the fact that there are many doctors in the country and many personnel working in the various regional health departments who care about this, they are helpless. They are not able to do anything about the poor services being offered. The policy of the Department is something that worries me and sometimes I wonder whether the Minister's officials are not influenced by that guru in Trinity College who believes that none of these cancer testings should be done for women. He has been getting greater and greater publicity recently in saying that it does not matter whether you test for cervical cancer or breast cancer, women will die anyway. It is a very dispiriting approach and it is contrary to worldwide trends.

Let us look at the situation. Women are being badly served at present by the service they are getting in the country. Most women are aware of the benefits of smear testing but few have availed of them. This is illustrated by a European public opinion survey done in September 1987 on the prevention of cancer. This showed that knowledge and awareness is very high among women but correspondingly the number of women who have availed of smear testing is very low. An example is that while 86 per cent of Irish women know about testing only 30 per cent have availed of it. We have a high awareness level here but a low take-up. We can compare this with the take-up in other countries which is 45 per cent in Denmark, 46 per cent in Germany, 60 per cent in France, 61 per cent in [833] Luxembourg and 55 per cent in the UK. Ireland compares very unfavourably with those. This is related to the fact that outside Dublin there are towns where there is no health centre providing cervical smear testing facilities, and similarly in such towns there are general practitioners who are not offering this service. That leaves women with no facility whatsoever unless they come to one of the family planning centres where they have to pay, in Dublin or in other big towns.

I am asking the Minister to focus some attention on this for a number of reasons. There was a recent Eastern Health Board report which showed that few women in the high risk groups come forward for cervical smear testing. These high risk groups are women over 50 years and women in the lower socio-economic groups. Because 1988 is the Europe Against Cancer Year and the EC is launching a code against cancer in the week 1 to 7 May next which will result in a great demand for screening services, this should be matched with good back-up facilities. There should be information, availability of screening services and a good, fast system for giving the results of these screen tests.

I am very unhappy with the general approach of the Department of Health in this area. I would like to quote some recommendations from the Eastern Health Board report on the availability of cervical testing. The recommendations they made were that a national committee should be appointed and charged with organising an effective programme for cervical cancer control. It should be specifically organised as a public health centre control programme directed towards a significant reduction in mortality from cervical cancer. The committee should engage a community physician as director who would be responsible for the day-to-day organisation of a screening programme and also would be accountable for its delivery.

A well organised laboratory service for reporting on smears must be provided. Information systems must be such as to [834] enable satisfactory monitoring and evalu-tiaon of the scheme. A specially designed education programme is essential and it should be directed at the high risk groups. Cervical screening tests must be made widely available through family doctors, hospitals, clinics, and information linkage is essential. They make in all 12 or 13 recommendations and I am quite sure that the Minister of State is familiar with these.

We are talking here about health prevention and a measure that has a proven record. In other countries, notably Sweden and Norway, cervical cancer has been virtually eliminated because of a realistic national screening policy over the last ten to 15 years. At present we know that this cancer is affecting younger women because there is now a more aggressive virus around and that early cervical cancer is related to earlier sexually activity. It is preventable. Cervical cancer can be detected in its preinvasion stage and treated successfully. A major handicap in the establishment of a successful cervical screening service is the dearth of information on the existing services and its clients. While figures are available regarding the number of smears tested during 1986, it is difficult to ascertain the actual number of individuals who were screened for cervical cancer that year. There is no proper record.

I want this problem addressed because it is unreal and it is not even good health policy that we do not know exactly what is happening or what is available in various parts of the country. We are not involved here with some new and untested medical technique. We are talking about an established process that can save lives. I suggest that the Minister of State should not be thinking at present about initiating any more studies or setting up any more task forces or committees. They are delaying tactics and allow the Minister of State and his Department to sit on the fence on this issue.

That is what is happening in the related health area of breast cancer screening. In this country around 574 women per year die of breast cancer. Yet, mammography, which is an X-ray of the [835] breast, has been established as an important detection tool by doctors worldwide. I refer particularly to the Forrest report, produced by Sir Patrick Forrest of the University of Edinburgh last year. It stated:

There is now unequivocal evidence that screening — using a technique of X-raying the breasts called mammography — could reduce deaths from breast cancer by about a third, possibly more. About 13,000 women in Britain die from this disease every year.

This benefit clearly is evident only in women over the age of 50. Current studies need more time before they will establish how useful it is to screen younger women.

Doctors are not yet sure how often a woman should have mammography — perhaps once a year, perhaps once every three years. Further studies will provide the answers.

That report which was drawn up by a UK working group on breast cancer screening, which was chaired by Sir Patrick Forrest, has come out with very valuable evidence for all of us. Health Ministers in Britain have accepted its main conclusions and are now implementing a screening programme.

I know that the Department of Health's response to requests for action on this issue perhaps will be to say that this work requires precision machinery and carefully trained personnel. As far as I know, that was the response to a question in the Dáil. Of course, it does. It is right and proper that we should have the best precision machinery and well trained personnel but this equipment is not outlandishly expensive to buy or the staff impossible to find. I do not think it is good enough to say that these are prerequisites.

It is a disgrace that we do not have even one centre which carries out a proper breast screening programme of women of 50 years and over and this despite the fact that there is conclusive evidence in the United States, Sweden, Holland and now in Britain to show that [836] mammography screening properly done on women over 50 can save lives. The estimated cost of screening women every two years, starting at the age of 50 and continuing until the age of 70, is about £120 per individual. That is the cost as outlined in the Forrest report.

I accept that the financial situation in this country does not allow a service such as the one which exists in England. Of course, I accept we cannot have screening programmes. I would very much like to have them but we cannot have screening programmes for breast cancer nationwide. A start should be made by having at least one centre with one programme. I suggest that if we continue with the kind of policies that are being put forward for women's health in these particular areas, we will be left very far behind in new techniques for preventive health for women. I suggest that the Government should have a role in this area. As I have illustrated, we are way down the league in either European or worldwide statistics.

Minister of State at the Department of Health (Mr. Leyden): I wish to express my appreciation to Senator Fennell for raising this matter and her views will be carefully noted by the officials of my Department. Over the past few decades health professionals have been placing increasing emphasis on the scope for preventing cancer. On the basis of current statistics, it appears that about one-third of the deaths from cancer are due to smoking tobacco, while another third appears to be from dietary factors. In 1986, more than 400 women died from cancer of the lung. One of the most effective ways to prevent lung cancer is to encourage people to stop smoking. The causes of cancer of the cervix and the breast have not yet been identified but the early onset of the disease can be detected by screening programmes. I am very much aware of the anxiety and concern felt by women regarding cervical cancer and breast cancer and I welcome this opportunity to talk about the importance and efficacy of screening programmes for these serious illnesses.

In 1986, there were 58 reported deaths [837] from cancer of the cervix. The PAP smear test is recognised as a reliable method of testing for carcinoma of the cervix. Under existing arrangements, a woman may avail of a smear test through her general practitioner, at clinics organised by health boards, maternity hospitals and family planning clinics. A diagnostic laboratory service is available at several hospitals throughout the country. To clarify one point raised by Senator Fennell, the laboratory service for smear testing at St. Luke's Hospital was suspended last year for a few months to clear a backlog but it is now open again and working normally. More than 135,000 smears were examined in laboratories in 1986. The service is available without charge to women who are exempt from charges under the Health (Out-Patient Charges) Regulations, 1987.

Cervical screening is available at present to any woman who wishes to have a smear test. Other countries have gone further and provided a comprehensive screening service for all women or those most at risk of contracting the disease. An Eastern Health Board Report on Cancer of the Uterine Cervix, prepared in 1986, suggests that the nature of the disease in Ireland is similar to that reported in international studies. These studies have shown a greater incidence of cervical cancer among women from lower income groups, older women and women of high parity.

I am of course, anxious to ensure that the cervical screening programme is utilised properly by women most at risk from the illness. The failure of the British cervical screening programme to reduce signifantly deaths from cancer of the cervix since its inception suggests that a great deal of thought must be given to ensuring that women most at risk from the disease will be encouraged to come forward for testing.

A study of current arrangements for cervical screening is at present being undertaken by the Faculty of Community Medicine of the Royal College of Physicians in Ireland on behalf of the Department of Health. The objectives of the project are:

[838] 1. To review the present organisation of services by addressing such questions as where services are currently being provided, and by whom, what, if any, is the target population, what are the characteristics of the population utilising the service, and what resources are being devoted to the service.

2. To evaluate the service against the criteria suggested for a successful screening service.

The project is funded by my Department and is expected to be completed in June of this year. The question of a comprehensive screening service will be reviewed in the light of the recommendations emanating from this study.

In the meantime, the Minister for Health has established a working group representative of medical and administrative experts in the field. I appreciate Senator Fennell's views on the various reports but we felt it was necessary to establish the working group with the following terms of reference:

—to examine the current arrangements for the taking and analysis of cervical smears;

—to recommend how current arrangements can be improved to deal satisfactorily with the present workload;

—to identify the target population and optimum frequency of screening for an efficient and cost effective cervical screening programme for this country and to recommend how such a programme be developed.

The Minister has requested that the working group report as soon as possible.

Breast cancer is a signficant source of morbidity and mortality. In 1986, 574 women died from the disease. Women most at risk from breast cancer are those aged 50 and over, those with a family history of breast cancer and women with a previous cancer episode in a breast. The disease is associated with considerable trauma and distress, particularly when treatment involved mastectomy.

[839] The purpose of a breast cancer screening programme is to detect breast cancer at an early pre-invasive stage. Screening methods include self-examination, clinical examination and mammography. Recent international studies have suggested that mammography as a screening strategy is beneficial to women over 50 years of age in terms of reduced mortality and gains in life expectancy. Mammography is available in this country in a number of hospitals. At present, however, mammography in Ireland is used largely as a diagnostic tool for symptomatic or worried women and, in some cases, for at risk women. However, self-examination is vitally important. General practitioners and the public should be made aware of the fact that the mammography service is available to all in all health board areas, with the exception of the Midland Health Board area which is close to the Dublin hospitals.

As a member of the European Community, Ireland is involved in the Community's “Europe Against Cancer” programme for 1987-1989. In the Europe Against Cancer Programme, Proposal for a Plan of Action 1987-1989 it is stated that in the majority of the countries of the European Community there is a lack of equipment and specialised staff, and because of this, systematic mammography is a long term objective in many countries. A survey carried out last year into the attitudes of Europeans to cancer prevention found that while 58 per cent of those surveyed were aware of the value of mammography, only 13 per cent had actually had mammography.

As some of you will be aware, the report of the United Kingdom working party on screening for breast cancer was published last year. The remit of the working party was to make policy recommendations with respect to breast cancer screening and the place of mammography and to consider the implications of their implementation. The British Government have accepted the proposals in the report and have decided to implement a national breast cancer screening service which will provide for screening every [840] three years for all women aged between 50 and 64 throughout the United Kingdom. We will in this country be looking at the results of this programme with great interest.

It is obvious that early diagnosis is important in the successful management of this disease but medical opinion is not yet completely agreed as to the efficacy and reliability of mammography as a means of mass screening. This is because the yield from mammography screening programmes is dependent on the type of equipment used and the expertise of staff carrying out the technique. As mammography facilities are relatively new to this country, it has not been possible to carry out any random controlled trials to evaluate the facilities. The question of developing the existing service as a screening service will, therefore, have to take into account the outcome of further studies, the outcome of the new programme in Britain and the availability of resources for such a programme in Ireland.

I should like to express my appreciation to Senator Fennell for raising this important matter. The more publicity generated about early detection the better. I should like to assure Senators that the Department are aware of the problems in this area and that, within the limited resources available to us, it will be given greater emphasis.

Mrs. Fennell: Is the Minister aware that the mammography he spoke of is not generally available, that it is only for referral cases with symptoms? Is he aware that it costs in the region of £75? We are not talking about something that is readily available. Will the Minister agree to establish a pilot scheme associated with one of the programmes in order to keep in tandem with what is happening in other countries?

Mr. Leyden: GPs can refer patients for mammography. I agree that a pilot scheme would be worthwhile but it is important to point out that self-examination has been found to be most effective.

[841] Mrs. Fennell: It is useful but at the end of the day mammography is the best.

Mr. Leyden: A patient cannot be referred for this screening unless there are some indications of cancer. The earlier cancer can be detected the better. We should encourage those in the high [842] risk category to have the test. Mammography may not be well known and we will endeavour to publicise it. We will also consider a pilot scheme, as suggested by the Senator.

The Seanad adjourned at 5.25 p.m. until 12 noon on Thursday, 28 January 1988.