Michael Harty (Clare, Independent)
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The purpose of this part of this afternoon's meeting is to engage with the chairperson designate of the National Cancer Registry Board, NCRB, Dr. Jerome Coffey, in order to discuss his strategic priorities for the role and his views on the challenges currently facing the board. The committee welcomes the opportunity to meet with Dr. Coffey and hear his views. On behalf of the committee, I welcome Dr. Coffey.

I draw the attention of witnesses to the fact 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. However, if they are directed by the committee to cease giving evidence on a particular matter and they continue to so do, they are entitled thereafter only to a qualified privilege in respect of their evidence. They 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, persons or entity by name or in such a way as to make him, her or it identifiable. Any submission or opening statement to the committee may be published on the committee's website after this meeting. Members are reminded of the long-standing parliamentary practice to the effect that they should not comment on, criticise or make charges against a person outside the House or an official either by name or in such a way as to make him or her identifiable.

I invite Dr. Coffey to make his opening statement.

Dr. Jerome Coffey:

I thank the Chairman and committee members for the invitation to appear before them. I am honoured to have been nominated to chair the National Cancer Registry Board. In this brief opening statement, I would like to focus on the development of cancer services in Ireland over the last decade, the central role of the National Cancer Registry Board in this and the likely direction of short and medium-term developments.

By way of introduction I am a radiation oncologist, appointed to the St. Luke's radiation oncology network in 2006. I succeeded my colleague and mentor, the late Professor Donal Hollywood, as radiation oncology adviser to the national cancer control programme in March of 2010 and, at the end of 2014, I took on the role of director of the national cancer control programme within the HSE.

In May 2015, the steering group and patient forum charged with developing the third national cancer strategy were established and they concluded their work two months ago. It became clear through my work as a member of the steering group how much has changed in cancer services since publication of the last strategy in 2006. The programmatic approach and the national scale of organisation and investment have been commended by an international external evaluation panel and are in perfect alignment with EU cancer control principles.

The concentration of specialist staff in the designated cancer centres has enabled multidisciplinary decision-making and the co-ordination of patient-centred care. At the same time, there has been integration between primary care and hospital care with collaboration between the national cancer control programme and the Irish College of General Practitioners on developing referral guidelines and electronic referral systems for common cancer types.

In preparation for today’s meeting, I have reviewed the National Cancer Registry Board (Establishment) Order of 1991, under the Health Act 1961, and the 1996 and 2009 amendments to the order. I have read the annual reports and accounts from 2007 onwards and I have made contact with the outgoing board chair and all current board members.

The statutory functions of the NCRB are to collect and analyse information relating to the incidence and prevalence of cancer and to promote and facilitate the use of the data thus collected in approved research projects and in the planning and management of services. By international standards, the registry has been hugely successful in fulfilling these functions. For example, completeness of population coverage is 100%. Registry data are used as the starting point for all local and national cancer service design projects.

Based on the work of the registry, we know that the incidence of cancer will go up by 50% between 2015 and 2025 and by approximately 100% by 2040. These figures underline the importance of the third national cancer strategy, to be published by the Minister shortly. From this, several things have to happen as a matter of urgency. Approximately 40% of cancers can be attributed to lifestyle factors so we have to focus heavily on cancer prevention, good examples being the Healthy Ireland initiative and HPV vaccination. Second, we have to stress the importance of early diagnosis, screening, direct access to diagnostics for GPs and a net increase in the capacity of the health care system to absorb the very significant projected increase in patient numbers.

The increase in the number of both patients and long-term survivors will generate a very large volume of additional data for the registry to collect, analyse and share. To meet this challenge, there is a clear opportunity to automate and facilitate data collection from hospitals by linkage to the national medical laboratory information system, MedLIS, the national medical oncology clinical information system, MOCIS, and other clinical datasets. The registry makes its anonymised data freely available to inform clinicians, health care providers and external researchers. It has its own highly productive research output and this is going to expand significantly since the appointment of the current director, Professor Kerri Clough-Gorr, last year. This is an innovative joint appointment creating a new post of professor of cancer epidemiology at University College Cork.

I reiterate the importance of the national cancer registry as a critical element of cancer services in this country. The NCRB will become an increasingly important agency as we anticipate a return on Exchequer investment in prevention, diagnostics and treatment reflected by way of improved cancer survival rates and other outcomes. I would be honoured to contribute to its future.

Michael Harty (Clare, Independent)
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I thank Dr. Coffey and will open the discussion to the floor if members have gathered their thoughts.

Colm Burke (Fine Gael)
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I thank Dr. Coffey for his presentation. I read through his CV and it is extremely impressive. I thank him for all the work he has done to date.

On providing services for those who have cancer, we are experiencing many difficulties in recruiting consultants in particular, as well as junior doctors and nurses. Are we facing the same problem in cancer treatment and providing services for patients with cancer?

Dr. Coffey noted that approximately 40% of cancers can be attributed to lifestyle factors. Are we doing enough by way of education to deal with that, starting in schools and moving upward? I spoke to a coroner on Monday on a different issue and he made the point about the lack of knowledge among young people about an area that he has found himself dealing with. Education is about preparing people for future life. Have we done enough to incorporate lifestyle, whether it is what they are eating or physical activity - for example, into our education system from primary to secondary to third level - in trying to get that message across? If not, what would Dr. Coffey like to see change over the next five to ten years?

Dr. Jerome Coffey:

I am happy to take both of those questions. On the recruitment of professionals, I have not seen that as a real issue in the context of cancer specifically. This is probably because there is evidence of and a sense that cancer services and the environment in which cancer specialists work as a result of significant investment on the part of the State. Bringing people back has not proven to be a problem. A recent example of which I am aware is my replacement as a radiation oncologist in the St. Luke's network. Two or three posts were advertised and interviewed for at the same time. There were 11 or 12 applicants for three posts. That is a ratio one does not see very often in other posts in the service, which says a great deal.

In the context of other health care professionals, we depend increasingly on our health care nurses in oncology. Our external panel, which I mentioned, has commented on that. In the past couple of years, through the service planning of the HSE, we have focused on this and put money into training advanced nurse practitioners in oncology. We are filling those posts. We have community oncology, education posts and the national cancer control programme, so we are providing training and job opportunities at the end of it to ensure that these become attractive areas of the health service in which to work.

I take the Senator's point on prevention. This country led the world with the introduction of the ban on smoking in the workplace. That was for a particular age group. More broadly, Healthy Ireland has been a very high-profile initiative and the cancer control programme contributes to that. We have a cancer prevention element within the cancer control programme and my understanding, from the cancer strategy steering group's work, is that this would be developed. It is probably necessary at this point to engage formally with the Department of Education and Skills on the strategy to see how we can contribute to the curriculum at primary, secondary and third level.

Margaret Murphy O'Mahony (Cork South West, Fianna Fail)
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Dr. Coffey is very welcome and I reiterate my colleague's comments about the Trojan work he does. I congratulate him on that.

How important is it to place greater emphasis on and increase funding for primary care in order to enhance indirectly the services that hospitals provide for cancer and other patients?

Dr. Jerome Coffey:

This is down to the foresight of my predecessors in the cancer control programme, Professor Tom Keane, Dr. Susan O'Reilly and Mr. Tony O'Brien. From the beginning there has been engagement with primary care. Electronic referrals are being introduced very broadly across the HSE. However, cancer control got there first with electronic referrals to the cancer centres for breast, lung and prostate cancers specifically. At the same time as resourcing software developments for GPs and the hard-copy referrals, there was work with the Irish College of General Practitioners and we have GPs on staff in the national cancer control programme to work out what the criteria are that mean it is urgent or non-urgent and that it should not be referred to the system. That is very important in getting patients referred appropriately and correctly into the system in order to get diagnosed and managed.

The next thing we need to work on is follow-up post-treatment. The latter is in the whole area of survivorship, which is being addressed by the cancer strategy. When someone is finished treatment, is well and there is no evidence of any active disease, his or her follow-up should not necessarily be in a hospital. The close-to-home principle applies. It needs to be community or primary care but there needs to be a linkage so that the information relevant to the care is transmitted to primary care without any effort. There needs to be a dialogue if a patient in follow-up in primary care has a problem and needs to get back into the system very quickly. All of that is critical. It is worth noting that the cancer control programme has made one if not two submissions to the negotiations relating to the GP contract and has made the point that resources need to be put into primary care in order to take the pressure off, but it is also more appropriate.

Kate O'Connell (Dublin Bay South, Fine Gael)
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I thank Dr. Coffey for coming in. He has large shoes to fill and has done very well. I am aware of how well he has done through a neighbour of mine. He has done amazing work in dealing with massive tragedy for people within his field, for friends and the greater community.

To focus in on the human papilloma virus, HPV, vaccine specifically, one of the things I felt got most traction from a public interest point of view was when the committee discussed the impact of the fall-off in vaccinations of girls who are eight years old now. We were able to extrapolate the data and it is a very powerful message to send to normal people going about their daily business. Does Dr. Coffey agree that it is the way we should be going? If we do not vaccinate correctly, many girls who are eight years old and who are walking around in flowery skirts will be dead by the time they are 40. These are shock tactics but it is so serious that an image should be created of girls or boys walking around and the impact of not taking up the vaccine. Is it the sort of methodology we should be using to inform people of the impacts? There is a great deal of misinformation out there.

Another thing that occurred to me in my work as a community pharmacist is the importance of GPs in this area. I did not realise that many people do not have GPs. They go to random doctors here, there and everywhere and perhaps to consultants if they are having babies. There is no contact with the GP unless they go private. Sometimes diagnoses of cervical cancer and things of that nature can just fall between two stools. I have seen it with people who are well educated and from very good socio-economic backgrounds but who do not understand the importance of having the basic level of intervention in the community. The importance of having a core person in charge of one's health care is something that needs to be highlighted. The GP is the person best placed to do that in the primary care setting. What are Dr. Coffey's views on that? How can we drive the message home? Some of us leave it to our 30s to have children and we throw them out every couple of years. That means some of us miss smear tests because we are trying to get pregnant and do not want to have a smear test. I have seen cases of cervical cancer being diagnosed when the person has gone eight years without a smear test. Cervical cancer is totally preventable and treatable. On those two issues, is there anything the committee or the Department can do to try to offset some of the effects?

Dr. Jerome Coffey:

There are a number of hugely important issues which I will try to separate out a little bit. As a parent and as an oncologist who has treated people with advanced cervical cancer and advanced head and neck cancer, they are disasters that can now be prevented. When one looks at other countries that have data because they started the vaccination system a little bit earlier, there has been a fall in the number of diagnoses. That is where the benefit lies. I agree entirely with the Deputy that the benefit did not feature in the headlines of the debate. In a democracy, it is important to have a debate. However, my sense is that much of the debate was based on belief and what people who may not have been highly health literate or scientifically literate felt was the case. Girls who had vaccinations developed symptoms but the science could not link the two. It was a complex debate. The Deputy is right that the main issue got diluted and perhaps lost. I would be happy to state that vaccination is important and it works. I worry that parents who make decisions on behalf of their children are influencing other parents not to vaccinate. We have seen a spillover from the HPV vaccination debate in other countries in Europe and in parts of the US, where people are not vaccinating against MMR. We are seeing fatalities from infectious diseases which we do not see anymore. It is horrific to feel we could have admissions to hospital and children dying because of the misplaced beliefs of the parents.

I will address the importance of the GP. Other countries have looked at this from the angle of health literacy, which we have to start doing. It is about doing awareness campaigns in the media about red-flag symptoms such as abnormal bleeding and lumps or bumps and telling people to go to their GP this week and not next month or a year from now. I have seen patients who have had a problem for a while and either they had a fear or some other reason for not presenting at an appropriate time and they go from a curable situation to an incurable one. They suffer from the symptoms of their disease simply because they chose not to present.

It comes back to the education programme. We need to get people to their GPs and to get GPs to support a secondary action, order immediate diagnostics or refer immediately so patients can be seen within a week or two at the nearest cancer centre. Health literacy should be a campaign. The National Cancer Screening Service provides BreastCheck, CervicalCheck and BowelScreen and is very good at what it does. It is a measure that is reflected in the numbers who attend for screening. Uptake is never 100% because we can make something available but we cannot make it compulsory. The challenge is in convincing people that it is in their best interests to get checked out. Most check-ups will be negative but at least it provides peace of mind for them, their families and their health care providers that they have had the appropriate tests and do not have a serious diagnosis.

Michael Harty (Clare, Independent)
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Yesterday, the Committee on the Future of Healthcare report was launched. It is a comprehensive report looking at a ten-year vision for the health service rather than going from year to year and trying to move from our two-tier system to a single-tier model. Does Dr. Coffey see the removal of private care in public hospitals as a positive or a negative in the treatment of cancer? As a committee, we were looking at a system which is not really working very effectively in the global sense. We will change it. We are concerned that if we destabilise it, there may be negative rather than positive consequences initially. We built a continuing review into our programme so that if changes are leading to a worsening of treatment for our patients, we will have to row back and look at the sequencing and phasing of it. What is Dr. Coffey's view on the mix of public and private in the public system?

Dr. Jerome Coffey:

I have followed the work of the committee over the past year and I met Professor Tom Keane before he made his submission. It was a very clear summary of what is happening in cancer services. With regard to the here and now, it is important to say that the cancer registry has a statutory basis. It has an obligation to retrieve cancer data from all hospitals whether they are publicly or privately funded. It has all the data it needs. There is a potential or need to modernise or apply a change. It is for the Department and its committee to consider whether we make cancer a notifiable disease so it is the responsibility of the hospital to report to the registry instead of the registry sending staff out to retrieve cancer health files from hospitals. To a large degree, that may not be too much of an issue if we get the technology right and export it automatically to the registry. It is the data collection for the registry. It will get easier as time goes by. It will have to because the volume of data will massively increase over the coming years.

With regard to the public-private issue, what is important is that the outcomes are the best possible for all citizens. Whether it is provided publicly or by a privately-funded facility, if they are applying high standards and if their reporting outcomes show that is the case, then the patient does well.

Michael Harty (Clare, Independent)
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Built into our report is a large section on e-health and the exchange and gathering of data. Obviously, data is king and the more data we have, the better we can plan our health services. I hope the hospitals would be returning data to the registry rather than it being a case of the registry having to go out and look for it.

Dr. Jerome Coffey:

Radiation oncology has electronic linkages with the cancer registry because there has been a lot of investment into information systems in radiation oncology over the last couple of years. The software is primarily for scheduling and controlling machines and treatment departments but it has a dataset which can be linked. It is already established. It is hoped that the medical oncology equivalent, which has been procured and will be rolled out over the next couple of years to all 26 hospitals delivering chemotherapy, will serve the same function.

Michael Harty (Clare, Independent)
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In my experience of referring patients on, I always recommend people go to the public system because all the back-up services and specialist services, the specialist nurses and ancillary services that are needed are all available. I do not want to throw any dark light on private care.

However, the public system gives much more comprehensive care in respect of cancer. In respect of the prevention of cancer, we also have a strong section in the report about health promotion and protection. That should start at school. Children should be educated on healthy lifestyles, diet, exercise, smoking and alcohol, which are huge contributors to cancer. It would appear to me that the uptake of cervical screening and mammography is poor, in the region of 50% to 70%. That is disappointing for a population-based preventive measure. What does Dr. Coffey think are the main factors at play?

Dr. Jerome Coffey:

This year, there was a media campaign by the screening service which had a measurable impact. When we remind people that the service is there and that it is free and beneficial, uptake increases. There is a very visible campaign for BreastCheck and the cervical check. That works. While the screening service is separate from cancer control, we work very closely together. Colorectal cancer screening worldwide struggles to get the same level of uptake as screening for other cancers. The colorectal screening programme in this country is relatively young but it is getting there. It will take effort to get to its target and that effort will have to be sustained. Once one cuts back on the marketing, if I can use that term, the uptake rates go down.

Michael Harty (Clare, Independent)
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Is it called colorectal screening? That is the stool test.

Dr. Jerome Coffey:

Yes. There was an NCI all-Ireland cancer consortium meeting in Queen's University, Belfast, a year or two ago and there was a special session on this. The other countries and jurisdictions doing colorectal cancer screening gave their experience, which was the same, namely, that it was hard to get uptake. Perhaps patients are embarrassed to be tested in that way or whatever. It takes continuous effort to get the rates up to a level at which they have an impact. What is also unique about colorectal screening is that it picks up pre-cancerous lesions. It does not necessarily find much cancer but does find a lot of polyps that would otherwise have developed into cancer over time. That is a much longer-term benefit.

Michael Harty (Clare, Independent)
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In respect of HPV vaccination, is there a plan to extend it to boys?

Dr. Jerome Coffey:

There have been plans. It is a while since I looked at it. As far as I can recall, there have been submissions through the Estimates process in previous years to extend the programme to boys. The Irish Cancer Society, with which I speak on a regular basis, is a very strong advocate of this and I support it. I understand that due to the fall in uptake this year there are supplies available that could be rolled out and administered to boys. Again, it would require a logistical probe to make that happen.

Michael Harty (Clare, Independent)
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Is there a cost implication?

Dr. Jerome Coffey:

In using up existing stocks there is no additional cost, as we have already bought them. In the longer term, I think it is a wise decision to make.

Eugene Murphy (Roscommon-Galway, Fianna Fail)
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I welcome Dr. Coffey and wish him well in his role as chairman of this very important group. The National Cancer Registry is vital and important. He and his colleagues have done amazing work in recent years dealing with cancer-related issues. If I may say this gently, I think that in many respects they have taken a lot of the fear away from people who are scared, as many people now survive and have quite a normal life.

The hospice movement now plays a major role in after-care all around the country. In my own constituency of Roscommon-Galway, Mayo Roscommon Hospice intends to develop a building on the grounds of Roscommon University Hospital. It has raised the funds and the Minister for Health, Deputy Harris, has agreed that the staff funding costs will be looked after by the Department. Looking at the figures here, the difficulty is that such staffing cannot be afforded by the Department until about 2020. That is a long time given the growing percentage of people who are suffering and will suffer from cancer. Up to 2025 there is to be a 50% increase, and up to 2040, some 100%. It is a shocking figure. Is there a way in which we could fight to try to get that staffing issue sorted out more quickly? It really is extremely important to the whole after-care scenario.

Deputy O'Connell referred to the vaccine. The difficulty I have is that when some families speak about the after-effects on their child, it is hard not to listen and be concerned. Obviously the vaccine is really important. How can we reassure the growing number of parents who are deciding against getting the vaccine for their daughters? If all of the experts are recommending it, it is very important that it is done.

Dr. Jerome Coffey:

I agree entirely with the Deputy on palliative care. The hospice movement has been hugely successful here. One of its successes has been finding alternative sources of capital funding to build facilities that were not there beforehand. In terms of funding for the future, a couple of things need to happen. Without betraying confidences, in the cancer strategy there is a recommendation that the cancer control programme in the Department of Health integrate palliative care. There is a HSE palliative care programme and we work very closely with Dr. Karen Ryan, who is the lead physician on that. We need to have palliative care integrated with cancer control programmes in order that we are not neglecting that part of the service and there is no geographical neglect either. In terms of funding, I take the Deputy's point. More staff means more funding. Overall, though, the biggest driver of cost in cancer care is drugs. The cost of cancer drugs is massive. They are more effective than before and have fewer side effects and consequently we want to be able to fund them for our population but that is the biggest element in driving the total cost of cancer. The provision of personnel is important and will happen. It will not be as difficult to achieve as the funding of cancer drugs over the next 20 years.

On the vaccination point, it is very difficult when one is talking to parents whose child is ill and became so after vaccination. It is also important to say that potential side effects of vaccines are reportable events. There is a data collection process for that. At this point, the scientific evidence and guidelines coming from the European bodies do not link the two. If there was any evidence that added up to a note of caution or precaution, then the cost-benefit of vaccination would be entirely different. Were we to state it is very effective at reducing the risk of various sorts of cancers in the long term but there is a 5%, 10% or 15% chance of permanent side effects from a vaccine given at a very young age, the decision to be made by parents would be very different. Having put all that together, the scientific evidence and guidance is that vaccination is effective. The causative link between the vaccination and the side effect that some children are experiencing has not yet been proven. If that were to change there would be absolute urgency to change the policy. Until that point, the cost-benefit is still in favour of vaccination.

Michael Harty (Clare, Independent)
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On that point, have the girls who have reported side effects as a group been studied in Ireland to see the commonality of their symptoms?

Dr. Jerome Coffey:

I am not aware of what has been done with the data collected in Ireland. It comes under the remit of the immunisation office and health and well-being, different divisions of the HSE. I have not seen documentation about Irish data.

Michael Harty (Clare, Independent)
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Dr. Kevin Kelleher was here a number of weeks ago. In the HSE literature, there was a reference to care pathways for patients with symptoms. He said that care pathway was not specifically for girls who have identified symptoms post-vaccine. It was for the general population who may have symptoms. It appears to me that if we want to increase the vaccination rate, we really need to approach the cohort of girls who feel they have been affected. They should be examined medically. That is the only way to distinguish between background symptoms that occur naturally and an increase in incidence occurring after vaccination. Until something like that is done, the negative attitude to the vaccine will continue. Pretending, or rather proposing that there is no association is not going to increase vaccination rates. It has to be proven that there is no association.

That is something the Department should take on board.

Dr. Jerome Coffey:

I do not have any specific information on the pathways, but I absolutely agree with the principle that the data which would prospectively be collected would also provide supportive care. Health care could reserve resources for patients who may have symptoms that arise following vaccination. That would provide reassurance for parents and their patients that they will not be abandoned and that they will be listened to. It might produce important data in the longer term, which would support us in refuting any possible link.

Michael Harty (Clare, Independent)
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There is a sense that they are not being taken seriously. One appreciates that there is no scientific connection, but nevertheless their worries and concerns need to be collated and respected.

Bernard Durkan (Kildare North, Fine Gael)
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My apologies for arriving late. I have read Dr. Coffey's statement. A couple of points arise. I was probably responsible for having the National Cancer Registry set up in the first instance because I asked so many questions that somebody decided it was time to move on with it.

To what degree has the incidence of the various forms of cancer throughout the country, and any potential cause or causes, been identified and collated? Do we have absolutely accurate information on that? Every time I followed up on this matter previously, comparisons were made that I could not necessarily always agree with, based on my own information - comparisons made per 1,000 or the population and so on for instance. I remember at one stage the incidences in Donegal and Tipperary were quite similar and that was not the information I was given in reply. The populations were similar, so the only other difference there could have been was the age profile of the populations. Obviously if data on the various forms were collated properly comparisons could be made. In general, huge strides have been made in the treatment of cancer, which is great. We should always try to have our statistics as up to date as possible. If we have the statistics available on the number of incidents, the type and forms of cancer, the degree of treatment provided and which appropriate treatment was given, it gives us an advantage in terms of being able to deal with future issues.

The last point is in respect of vaccinations. We have had this debate on a number of occasions. It can be difficult. My own layman's theory is that different people's metabolisms react differently to certain treatments. I cannot prove that but I have seen and heard evidence to suggest that it might be so. I know as well that in general, inoculation will have the biggest single effect on the broad sweep of cases that appear right across the community. The side effects, however, can affect a number of people and whether they are directly attributable to vaccination remains to be seen. We do not have information to that effect despite the exhaustive pursuit of cases such as my colleagues have referred to. It would be useful if we did, because confidence in the system can be eroded if somebody is not able to tell us plainly that, in a given case, a person's child should not have had a particular vaccine because of its composition and the child's metabolism. We have no way of knowing how to cross that Rubicon in the beginning because, at that particular age, the parent does not know what their child might be vulnerable to. We await, in good faith, the best information we can get from those who are best capable of providing it. We know that the broad thrust of the issue might be best dealt with by way of vaccination, which would have the biggest single effect across the board, but we do not know what percentage of the population might not benefit, whether it be 5%, 10% or a figure in between. That information would be helpful.

Dr. Jerome Coffey:

To take Deputy Durkan's points in reverse order, his last point is very interesting, because we are currently at the point in cancer care where we are looking at the genetic make-up of a patient with a tumour to determine whether he or she will respond to treatment. If he or she will not respond, we can choose not to give him or her the treatment, which would only cause side effects. If we were in a position five or ten years down the road, or sooner, to determine from a blood test a person's genetic make-up, the likelihood that he or she will benefit from a vaccination and the likelihood that he or she will develop side effects, it would completely change and enhance the way in which we make those decisions. That point is well made.

The first point was about data and geographical variation. The National Cancer Registry is excellent at putting up on its website heat maps or distribution maps illustrating where there are higher incidences in one location compared with the national rate. It is interesting to look at these maps. If one looks at the slides it put up this week, which illustrates the newest data from the period up to 2014, one sees higher incidences in metropolitan or city areas for most of the common cancers. When one looks at a report it put out a year or two ago, under the direction of Dr. Harry Comber, about inequality in incidence, it considered at a number of factors. It looked at differences between young and old. There is a higher incidence in the older age group. It looked at socio-economic factors, which is probably an area in which we could have an impact if we focused education and intervention in the lower socio-economic areas where there are higher rates of lifestyle-related cancers such as head, neck and lung cancer. The report also looked at rural and urban living as factors. There is a higher incidence of some cancers in rural areas. People will not move to the country just to mitigate that risk but I take the Deputy's point on the importance of data and interpreting it to guide where to focus investment and where developments need to take place.

Michael Harty (Clare, Independent)
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I thank Dr. Coffey. In his opening statement he said that the incidence of cancer will go up by 50% between 2015 and 2025 and by approximately 100% by 2040. Will he outline the factors which influence those increases?

Dr. Jerome Coffey:

The first thing to say is that the previous projections of the National Cancer Registry were found to be true, so I would expect these projections to also be true. There are a number of issues here. One is the size of the population and its age profile. Those were all taken into account in the model. The modelling work is quite complex and I do not understand the statistical element myself. It says, however, that an increase such as this is inevitable. The only way we could seek to bend the curve or reduce the number of new cases would be to focus strongly on lifestyle factors at this point. These include smoking, and smoking rates are coming down, and reducing the alcohol intake. These are lifestyle changes that we know about. Unless those efforts are redoubled now, we will see the doubling to which the Chairman referred and we will see a lot more patients coming through. We would hope that, with current treatment technologies, we will get better outcomes for those patients but one would prefer not to be a patient, even if one survives one's treatment.

Michael Harty (Clare, Independent)
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There is an advertisement running at the moment, which I believe is sponsored by the Irish Cancer Society, which suggests that one in eight cancers is related to alcohol intake. Will Dr. Coffey elaborate on that?

Dr. Jerome Coffey:

There are a couple of facts like that which are very blunt and hard to avoid. When one thinks about alcohol, one thinks about various things, but one does not think about head and neck cancer, oesophageal cancer and other gastrointestinal cancers. With smoking, one thinks about lung cancer, but one does not think about head and neck cancer, which is as morbid and as fatal. One does not think about bladder cancer. These common risk factors can cause a multiplicity of problems, both cancerous and otherwise.

Michael Harty (Clare, Independent)
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Is alcohol associated with one in eight cancers?

Dr. Jerome Coffey:

Yes.

Michael Harty (Clare, Independent)
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Does that refer to breast cancers or all cancers?

Dr. Jerome Coffey:

The facts which I have come across recently suggest that the lifetime risk of developing breast cancer for a woman in this country is between one in eight and one in 12. A proportion of that risk is due to alcohol intake.

Eugene Murphy (Roscommon-Galway, Fianna Fail)
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May I ask one brief question on that? Listening to the experts, I think we all now know that alcohol and smoking are detrimental in terms of people developing cancer. Have other factors such as food or environment been indicated? Are there any indications that such factors may be a cause?

Dr. Jerome Coffey:

There are two parts to the answer. I joined the scientific council of the International Agency for Research on Cancer last year. It is an international organisation based in Lyon, which is run by the World Health Organization, WHO. It looks at carcinogens. It looks at chemicals, foodstuffs and anything else that may be causing cancer. It looks at various parts of the world. If an area of high incidence is found it looks at what local issues might be contributing. In terms of foodstuffs in this country or other lifestyle issues, nothing major has been noted.

Radon in parts of the country contributes to a certain proportion of the incidence of lung cancer. There is nothing obvious at the moment that needs to change from good status to bad status that will have an impact on incidences of cancer.

Michael Harty (Clare, Independent)
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I thank Dr. Coffey and wish him the best of luck in his chairmanship of the National Cancer Registry Board. We may engage with him again in the future if he is amenable to that.