Pádraig Rice (Cork South-Central, Social Democrats)
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We have received apologies from Senator Nicole Ryan who is on maternity leave. I remind members of the constitutional requirement they must be physically present within the confines of the Leinster House complex in order to participate in public meetings. I will not permit a member to participate where he or she is not adhering to this constitutional requirement. Therefore, any member who attempts to participate from outside the precincts will be asked to leave the meeting. In this regard, I ask any members partaking via Microsoft Teams that, prior to making their contribution to the meeting, they confirm they are on the grounds of the Leinster House campus.

Today the committee will consider priorities for the next cancer strategy. Cancer is an issue the committee has looked at a number of times. It is a key priority for many members. While there is no doubt that patient outcomes have improved in recent decades, complacency is undercutting some of the gains that have been made. In particular the absence of sustained multi-annual funding in the current strategy has meant too many people now face delays in accessing testing and treatment. This is borne out in the numbers with targets consistently missed and regional inequalities persisting. Our cancer service used to be the jewel in the crown of our health services but unfortunately that is no longer the case. We should aim to be the leaders in Europe in terms of cancer care and not settle for middle of the pack or just above.

In advance of the new cancer strategy a distinction must be made between strategy and implementation. It is not good enough just to publish a strategy. We need to have much firmer focus on delivery. This is something the committee will continue to press for.

To assist the committee with this matter, I welcome from St. Vincent's UCD cancer centre, Dr. David Fennelly, oncologist and clinical director of the Dublin and South East cancer network; from the Swedish Institute for Health Economics, Dr. Thomas Hofmarcher, health economist and research director, who is joining us online; and from the Irish Cancer Society, Ms Nikki Gallagher, CEO, and Ms Emma Harte, head of policy. Witnesses are reminded of the long-standing parliamentary practice that they should not criticise or make charges against any person or entity by name or in such a way as to make him, her or it identifiable or otherwise engage in speech that may be damaging to the good name of a person or entity. Therefore, if their statements are potentially defamatory in relation to an identifiable person or entity, they will be directed to discontinue their remarks. It is imperative they comply with any such direction.

Members are reminded of the long-standing parliamentary practice to the effect that they should not criticise, comment on 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 now invite Dr. Fennelly to make his opening remarks.

Dr. David Fennelly:

My name is David Fennelly. I am a medical oncologist practising in Ireland since 1996. I am clinical director of the St. Vincent's UCD cancer centre Dublin and HSE cancer clinical lead for the Dublin and South East cancer network. I thank the committee for the invitation to speak to it today about cancer care in Ireland and the next national cancer strategy. I am joined today by my colleagues, Mr. Tommy Bracken, my strategic director, and Ms Paula Carroll, business manager.

Ireland stands at a pivotal moment in the development of its cancer services. The establishment of a national cancer network built around the designated cancer centres is fundamental to the further development of cancer services in Ireland. This network would formally align us with the European Network of Comprehensive Cancer Centres, EUnetCCC, and operate under the auspices of the National Cancer Control Programme, NCCP. This would ensure equitable, high-quality, and sustainably funded cancer care for every patient in the State, regardless of their home county. I believe this development will shape the next cancer strategy.

Ireland has had three national cancer strategies to date commencing in 1996 and bringing us up to the current day. The current strategy is due to run out at the end of this year. It has been hugely successful. On my return to Ireland in 1996, I was one of four medical oncologists in the country. We now have 50 with a ratio of 1 per 100,000 of the population. This has transformed cancer care delivery. We have improved and increased overall survival rates for our patients. We have demonstrated widespread improvements in quality of care and expanded the range of treatments available to our patients. We have a talented, highly skilled and eminently capable workforce through medical, nursing and health and social care professionals. It is their passion and commitment that has driven the high-quality cancer care delivered throughout the State. There have been many advances in the past two decades: the establishment of eight nationally designated centres; the establishment of the national cancer registry in 1991; the overall reform on how cancer is diagnosed and treated, particularly with regard to surgical centralisation; the establishment of the National Cancer Control Programme in 2006; the expansion of cancer screening and the establishment of national programmes in breast, colorectal, prostate and cervical cancers; and the renewed emphasis on healthier lifestyles and thus cancer prevention.

This progress has been achieved through sequential cancer strategies directed by an independently funded national cancer control programme. This funding model has now been changed, with funding devolved to the regions. This funding model is not working for cancer care. A new national strategy is required to build on the progress made to date. This must address the needs of cancer patients throughout Ireland, delivering optimal outcomes and best value for public investment. This, of course, is set against a backdrop of an ageing population, rising cancer incidence, rapid developments in cancer care and treatment, obvious capacity and resource limitations, and the clear requirement for greater integration with primary care and community intervention teams to provide seamless care for our patients before, during and after treatment.

Alongside this is a challenge of delivering clinical research to support clinical care and improving participation for patients in clinical trial activity, which will lead to improved overall outcomes.

The next national cancer strategy must focus on the development of a national cancer network with the NCCP as a governing authority. There must be enhanced co-ordination around national and supraregional designations for specific cancers, ensuring that appropriate expertise is available. The NCCP should retain responsibility for national designation.

Cancer care funding requires a predictable multi-annual budget. This needs to be ring-fenced for cancer care to ensure protection of our services. We need investment in our IT and data infrastructure to support this national network.

Bed capacity pressures are an ongoing issue throughout the country. We need ring-fenced and protected beds for our elective cancer patients to prevent treatment delays in elective therapies and to avoid deviation from KPIs and suboptimal outcomes.

We need to complete the implementation of the 2017 strategy. It is ten years old now. We need to complete surgical centralisation and we urgently need implementation of a national radiology plan.

Research is a key component of this national cancer strategy. We need a national clinical trial network to support and complement a national cancer network, thus providing timely and equal access for patients to clinical trial participation.

We must provide timely and equitable access to new drugs for our patients. We need to expand clinical genetics and genomics programmes to keep pace with new drug development. Throughout this process, patient and public involvement is key, with patient advisory groups assisting in the development of treatment pathways and new clinical trial design.

There are core pillars to a national network. These revolve around treatment, research and education. A network must ensure that homogenous OECI-approved treatment pathways are delivered throughout it. Clinical research and access to clinical trials must also be distributed throughout the network. Educational opportunities abound with the network, both national and international, with funded fellowships available for both our medical and our health and social care professionals.

Building on the regional structures and the designated centres, a networks approach is required. The Dublin and South East Cancer Network, of which I am clinical lead, is an example of this. The St. Vincent's UCD Cancer Centre, an OECI-approved cancer centre, acts as a hub for this region. In the network, each hub would extend OECI-approved treatment pathways throughout its network. It would ensure access to national and supraregional multidisciplinary team, MDT, meetings, and this would ensure rapid patient referral within each region. This, in turn, will provide patients with rapid access to state-of-the-art cancer centre-approved treatment delivered in their local hospital, co-ordinated nationally by the NCCP and benchmarked against OECI standards. The advantage of this network approach is that it utilises existing structures and, thus, significant additional funding will not be required. The Dublin and South East Cancer Network has been chosen as a pilot site for the EUnetCCC project. This is a Europe-wide project, funded to over €100 million, which aims to ensure access for more than 90% of patients to a comprehensive cancer centre network by 2030. We are proud to be a participant in this widespread European project.

The network model of care is well established among our European partners. With a population of approximately 5 million people, Ireland is ideally suited to a network model of cancer care, and this will place Ireland at the forefront of cancer care internationally. The NCCP would retain overarching governance and co-ordination, ensuring that national designations, supraregional services and screening programmes are organised coherently and operate to a common OECI benchmark standard.

I thank members for their attention. I believe that the networked model of cancer care is key to maintaining the successes of our cancer strategies to date and to ensuring that our patients continue to receive the very best in cancer care throughout the State.

Pádraig Rice (Cork South-Central, Social Democrats)
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Thank you, Dr. Fennelly.

I now invite Dr. Thomas Hofmarcher to make his opening statement.

Dr. Thomas Hofmarcher:

I thank the Chair, members of the committee and representatives of the Houses. I am very grateful for the invitation to appear before them, at least virtually. My name is Thomas Hofmarcher. I am a health economist and research director at the Swedish Institute for Health Economics. Much of my work focuses on cancer care and the comparative analysis of cancer care systems across European countries and beyond.

The reason for my invitation, as I understand, is a report called Cancer Dashboard for Ireland, which we published earlier this year. The purpose of that report was to look at Ireland's cancer care system from a comparative European perspective and to put forward recommendations for improvement.

My main message today is this: Ireland has made important progress in cancer control but the next cancer strategy should be more than a continuation of the current one. It should be a measurable, investment-backed, digitally enabled implementation strategy, aligned with European ambitions and informed by lessons from other European countries.

As Dr. Fennelly has just said, there are several strengths to build on. Ireland has now had three successive national cancer strategies, which have defined priorities, such as the introduction of organised screening programmes, and contributed to positive change. Most importantly, Ireland has seen marked improvements in survival over time. According to the national cancer registry, five-year survival for all cancers increased from 43% in the 1990s to 65% now. That is a 22-percentage point increase, which is a major achievement. However, the international comparison also shows that Ireland is not yet fully where it aims to be. The current national cancer strategy set the ambition for Ireland to reach the top quartile of European countries. The available data suggest that Ireland has generally been in the middle range among comparable countries and still trails countries such as Belgium, Denmark and the Netherlands. Therefore, the key question for the next strategy is not whether Ireland has made progress. It clearly has. The question is how to move from progress to consistently high performance across the whole cancer pathway.

I will now highlight five priorities that very much align with what Dr. Fennelly has already said.

First, the next strategy should start with a transparent evaluation of the current strategy. The critical issue with any strategy is implementation. What was delivered? What was delayed? Which targets were met? Which were not and why? The next strategy should be built on these lessons. It should include a strong governance framework that clearly defines who is responsible for each action, how it will be financed, when it will be carried out and how progress will be tracked transparently. Timely publication of annual progress reports should be a core part of this. The strategy should also be developed in consultation with a wide range of stakeholders and include sustained, multi-annual investment for implementation.

Second, Ireland needs stronger data and digital systems. One of the most important messages from our report is that cancer policy cannot be managed properly without timely, comparable and publicly available data. Ireland has a strong national cancer registry, but there are still gaps. For example, there is a reporting lag in incidence and survival data. In fact, as of last week, the latest data in the national cancer registry were from 2022. In Denmark and the Netherlands, by comparison, data for 2024 are already available. Comprehensive and up-to-date statistics on stage of diagnosis are also not routinely published annually by cancer type on the registry’s website. This makes it difficult to assess whether actions to improve early detection, including screening programmes, are having the intended effect.

To truly improve cancer care, however, we need to look deeper and understand the care process itself. The measurement of pathway performance is fragmented. Relevant indicators, such as time from suspicion of cancer to treatment initiation, use of biomarker testing and analysis of treatment patterns cannot be fully assessed using current public data. Nevertheless, the NCCP already monitors selected indicators internally and shares them with hospitals. The next step is to make pathway performance more timely, comprehensive and transparent.

The next strategy should therefore accelerate the digital for care programme and the introduction of unified national electronic health records. This is not just an IT issue. It is a patient safety issue, a quality issue and an accountability issue. Better data can reduce repeated tests, support faster referrals, show where bottlenecks occur and allow policymakers to see whether investment is improving processes and outcomes in real time.

Third, prevention and screening should remain central. Ireland has made great progress in tobacco control, but smoking prevalence remains well above the tobacco-free target. Harmful alcohol consumption also remains an important cancer risk factor. The next strategy should therefore continue strong tobacco and alcohol policies, with targeted approaches for groups at highest risk. We are also only four years away from the WHO target of eliminating cervical cancer as a public health problem by 2030. While HPV vaccination rates in Ireland are high, they are not yet reaching the global target of 90%. Digital consent forms for parents, reminder systems and a permanent catch-up vaccination programme are practical tools that could help strengthen uptake.

Screening is another area where Ireland has good foundations to build on. BreastCheck, CervicalCheck and BowelScreen are now essential parts of the cancer care system, but screening only works if people participate and participation is not equal across population groups. The next strategy should therefore focus strongly on outreach to groups with persistently low uptake. It should also extend breast and colorectal screening age ranges, aligned with updated EU recommendations, while using artificial intelligence support systems where appropriate to limit additional workforce requirements. For lung cancer, the Irish Cancer Society has championed the lung health check pilot. The priority now should be to use the pilot as a structured learning platform for future nationwide implementation of lung cancer screening.

Fourth, Ireland should strengthen timely and equitable care through standardised pathways and investment in capacity. High-performing cancer care systems are not only those with access to effective treatments. They are systems where the patient pathway is well organised, meaning clear referral criteria, timely diagnostics, multidisciplinary decision-making, co-ordinated care, access to specialist centres and rapid treatment initiation. Ireland already has nine NCCP-designated cancer centres and rapid access clinics for prostate cancer, lung cancer, breast cancer and melanoma. However, timely access remains a concern. The next strategy should define what timely, guideline-concordant care looks like across cancer types and then measure whether patients receive it, regardless of geography or point of entry into the system.

One concrete priority could be to establish standardised care pathways beyond the current rapid-access cancer types. Denmark, for instance, has around 30 standardised cancer patient pathways. This allows patients to move through the system according to clear, nationally defined timelines and responsibilities. In parallel, Ireland should develop a national roadmap for completing the European certification process for all NCCP-designated cancer centres and for linking hospitals across the country to these centres through clear referral pathways. It is about the idea of a national cancer network, as Professor Fennelly has explained. For these pathways to work, the next strategy must also invest in workforce, infrastructure, digital and AI-supported tools, advanced biomarker testing and multidisciplinary tumour boards.

Fifth, Ireland should strengthen access to new medicines and clinical trials. Cancer medicines were not a major focus of the current national cancer strategy. In fact, only one of the 52 recommendations explicitly mentioned cancer medicines, and that was in relation to the administration of oral medicines. This is surprising, because cancer medicines are one of the fastest moving areas of cancer care. Of course, timely access must be balanced with value for money, especially amid rising medicine costs, but this challenge is not unique to Ireland. Denmark and the Netherlands reimburse substantially more EMA-approved cancer medicines than Ireland and often reach decisions faster, while still applying principles of cost-effectiveness. The next strategy should therefore include clear aims for access to effective and cost-effective cancer medicines. Access to medicines is also closely linked to access to clinical trials. Ireland has seen increasing participation in cancer trials in recent years, which is encouraging, but the number of oncology trials per 100,000 inhabitants remains only about half that of countries such as Denmark or Belgium. The next cancer strategy should therefore follow through on the 2025 recommendations of the national clinical trials oversight group, including stronger governance, more efficient trial processes and greater patient involvement.

To conclude, Ireland is starting from a strong position, but the next cancer strategy should be designed for delivery. It should be measurable, funded over multiple years, digitally enabled and aligned with European goals.

Ms Nikki Gallagher:

I thank the committee for the invitation to speak today. I am the relatively new CEO of the Irish Cancer Society. I am joined this morning by my colleague Emma Harte, policy and campaigns manager. While I took on the leadership of the Irish Cancer Society relatively recently, the organisation has a long and proud history of campaigning to put cancer patients at the heart of public policy. It is my privilege to continue that important work. The Irish Cancer Society wants people affected by cancer to have the best possible outcomes possible. We are working hard to support cancer patients.

Over the years, my colleagues have provided trusted cancer information to patients, given them a reassuring and listening ear, implemented a transport service to bring people to and from their chemotherapy appointments and cared for people dying from cancer through our night nursing service. The Irish Cancer Society is also the largest voluntary sector funder of cancer research in Ireland, investing tens of millions in cancer research over the last 40 years.

Today we would like to talk about a future-focused approach towards producing and implementing the next national cancer strategy. Unfortunately, one in two of us will be diagnosed with cancer in our lifetime, meaning there is barely a household in Ireland that has not been affected by cancer. In fact, 44,000 people each year hear the words, “You have cancer.” By 2045, twice as many people will get a cancer diagnosis compared with 2015. We understand the challenge ahead, and we must now prepare the response to that challenge to better diagnose, treat and support cancer patients today and into the future.

The Irish Cancer Society is concerned that without multi-annual ring-fenced investment and strategic planning we will not be able to meet the challenge of rising cancer diagnoses in the next 20 years. Ultimately, this will mean we risk not gaining better outcomes for people affected by cancer. The decisions we make right now are quite literally life and death ones.

It is important to acknowledge, as other contributors have, that hard-won progress has been made here. Between the mid-1990s and the 2010s, cancer survival has increased from two in five people to three in five people. These results could happen because of targeted investment in programmes, infrastructure and the workforce so cancer could be detected at the earliest possible stage and treated as soon as possible. However, progress is at risk of stalling. Ireland’s current national cancer strategy was ambitious but realistic. Over the course of the last decade, the strategy was designed to improve early detection in cancer, set up Ireland as a leader among EU countries in cancer survival and reduce inequalities between the most- and least-deprived communities in Ireland. The current strategy has failed to deliver the promised outcomes due to underinvestment. There are great examples of projects which have worked very well to date and thereby brought benefit to patients. These include the acute haematology oncology service and the national cancer information system. However, we have fallen behind in a range of areas, including timely access to dedicated referral pathways for breast and prostate cancer; timely access to treatment which means there are delays to people getting the care they need when they need it - and providing the underpinning infrastructure and required funding for the implementation of strategic projects and service provision.

Without investment in the national cancer strategy it is patients who bear the real cost. Delays in starting treatment negatively affect mortality rates. The risk to patients and their outcomes are too high so it is essential we get the cancer pathway right. In simple terms the healthcare system cannot currently meet the needs of people seeking care today. In 2025 alone more than 11,600 women did not access an urgent symptomatic breast disease clinic within the recommended timeframe, more than 6,000 people did not get their urgent colonoscopy within timeframe, 1,300 people did not start chemotherapy on time and 1,500 people did not start radiation therapy treatment on time. The data from the first quarter of 2026 continue to show delays. Behind each of these statistics are real people, many of whom reach out to the society to tell us their story and experience. Our cancer nurses and front-line staff listen to their worries and their frustrations because the system cannot meet their needs. In the last number of years, the Irish Cancer Society has heard similar stories from many people, including people who are anxious because they cannot get to an urgent appointment for a breast exam or colonoscopy and people who are frightened and frustrated because they have been waiting months to get their surgery or to start their radiation therapy or chemotherapy and who are still waiting to hear about their appointment. Unfortunately, without the sustained investment in the necessary strategic programmes and infrastructure thousands of people have been waiting longer than recommended to get access to tests and treatment.

As we head into the budget cycle it is important to remember investing in services also saves the State money in the long term. Investment in cancer services will unlock a range of benefits for both cancer patients and the State. The sooner a cancer is detected and treated, the better the outcome for the patient. It is also more cost-effective for the State. Investing in our pathway and growing our survival rate to match the best-performing countries in the OECD and EU could save 20% more people from premature cancer deaths, bring the equivalent of 400 full-time workers back to the workforce and significantly reduce expenditure on treatment.

There is a high degree of unmet need across the cancer spectrum which also must be considered in the next cancer strategy. Cancer takes an enormous health, emotional, psychosocial and financial toll on a person and their household. As the current strategy comes to an end we have an opportunity to take stock of what has worked well and what should be done differently moving forward. People affected by cancer, as well as clinicians, advocacy groups and other stakeholders, must be involved in strategic discussions and in setting priorities. The next strategy should include a review of the breadth of new and unmet needs of people affected by cancer. We want to see an all-of-Government approach and coherence across related strategies supporting people across the cancer spectrum.

The priorities for the next cancer strategy should include prevention, screening, testing and treatment, meeting the needs of people living with and beyond cancer, dying well and innovative research. The success of the next strategy will depend on its priorities, funding and the processes underpinning its implementation. The next strategy must link actions to anticipated outcomes, have agreed operational plans, ring-fence strategic cancer funding, identify each of the stakeholders with responsibility for implementing the strategy, clarify the relationship between the centre and the regions in implementing the strategy, include continuous monitoring of progress and evaluation informed by timely data collection and publication of same and implement mechanisms for governance and oversight.

The list, of course, is not exhaustive. Crucially, people who are invested in cancer services need clarity on the timeline for evaluating the current strategy and developing and launching the next one.

It is important to note we all want the same thing here. People diagnosed with cancer, people who live beyond cancer, clinicians, staff planning and providing cancer services, civil servants, advocacy groups - including ours - politicians and members of Government all want the same thing, which is to save lives. There is not a person in this room who does not want to reduce the cancer incidence, make sure cancer is caught at the earliest possible stage, get people into treatment as soon as possible and provide them with the supports they need. We can choose this path forward. We can choose to invest in integrated pathways, embrace innovation and develop data infrastructure to help us plan and fund our services. Most importantly, we can choose to place people at the heart of cancer care to listen to them and to address their needs.

Pádraig Rice (Cork South-Central, Social Democrats)
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Thanks very much, Ms Gallagher. I invite questions from members. We use an agreed rota based on party size. Each member is given the same amount of time and members should direct their questions to the witnesses they want to answer. We aim to take a break in about an hour's time.

The first slot is for Fianna Fáil. I call Deputy Daly.

Martin Daly (Roscommon-Galway, Fianna Fail)
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Thanks, a Chathaoirligh. I thank the witnesses for coming and for their statements.

I want to reflect first. We had successive national cancer strategies. I am not so sure they were the jewel in the crown but I would certainly say they were the first attempt at a serious, mature reconfiguration and consolidation of cancer services based on evidence. Considerable political capital was expended, including Deputies in this Parliament losing their seats because they lost a cancer service in their local hospital. In order to maintain the confidence of the public in the consolidation of cancer services we need to deliver for them. I looked at the cancer dashboard. We have done well in certain areas but in research we are deficient and in prevention we are also deficient, which I am really surprised at. Regarding alcohol consumption and tobacco public health programmes we are deficient. I am really interested in the tobacco one because we pride ourselves on being one of the first countries in the world to ban tobacco smoking in the workplace when Micheál Martin was Minister. We are behind in colorectal screening. Our digitalisation is really stone-age compared with the rest of Europe. We have had witnesses in here before about access to radiotherapy. Access is poor and there is less than timely access to chemotherapy for breast cancer patients and for patients with other cancers as well.

I want to dive straight into it. I am really interested in the European Union’s target of having 90% of the population with access to a comprehensive cancer care centre by 2030. Dr. Fennelly is part of that pilot. Will the witnesses explain the network model to us? The only way we are going to get access to protocol-driven, internationally benchmarked care and early access to new medications and trials will be through this model. Perhaps Dr. Fennelly could explain what it entails.

Dr. David Fennelly:

I thank Deputy Daly for his question. I am immensely proud of the progress that we have made in Ireland in terms of cancer care. As I said, I do think that we are at a pivotal moment. The network model of care is key and Ireland is ideally suited, with a population of approximately 5 million people. The purpose of a network from a patient perspective is to put the patient at the centre of the process - what we want to do when we consider the important aspects of cancer care revolving around timely surgery, timely chemotherapy interventions and radiation therapy. Surgical centralisation is key, so there are centres that will be designated for specialist surgery. We know surgical outcomes are dictated by volumes and therefore we must focus on surgical centralisation.

However, what a network will do is take those OECI-benchmarked standards and treatment pathways out to the community throughout the network so that the patient can access state-of-the-art cancer care in their local hospital. They can access that care in the knowledge that it is OECI approved and dictated and directed by the regional cancer centre. They will also have access, very importantly, to clinical trial participation. Any clinical trial that is activated within the cancer centre hub will be exported throughout the network. Therefore, a patient can participate in a clinical trial in their local hospital. This is well demonstrated throughout Europe. I am sure Dr. Hofmarcher can speak to it in more detail in Europe as well. This is a model of care that is well practised in Europe. It is a key part of the next cancer strategy and the way we can ensure ongoing progress for our patients.

Martin Daly (Roscommon-Galway, Fianna Fail)
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It is almost a reverse of what we had 20 years ago when there was this drive to centralise everything – rightly so as it was based on evidence at the time - and outcomes have improved. As our population grows older and our capacity to deliver at those centres diminishes, we accept that surgical volume has to be centralised but protocol-driven chemotherapy and radiotherapy – certainly chemotherapy - can be done in local hospitals, maybe level 3 hospitals.

Dr. David Fennelly:

Absolutely. The treatment pathways will be directed by the local cancer centre. They will be OECI approved and benchmarked against OECI European standards. If I look at the south-east network, for example, I work closely with my colleagues in Waterford, Wexford, Kilkenny and south Tipperary. The intention would be that the network would link all of those hospitals and ensure not only OECI-standardised treatments throughout the network. A key part of it is if we come back to KPIs and access to treatment, there are two parts of access to treatment; access and capacity. What a network will do is ensure rapid access to the specialist unit.

Capacity remains a challenge. Nationally we are particularly challenged from the point of view of radiology, radiation oncology and pathology. What I really want to do is ensure that patients nationally, wherever they live, have rapid access to a specialist centre. Once they have access to the specialist centre, their treatment can very readily and should be delivered locally, co-ordinated by their regional cancer centre, which is done under the auspices of the NCCP, and ensuring standardised OECI-approved treatment pathways throughout.

Martin Daly (Roscommon-Galway, Fianna Fail)
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We are taking a small country like Ireland, which is literally the size population-wise of a major European or North American city, and we will have our national cancer network but we are also part of a European Union cancer network. The benchmarking comes from a population of 500 million people, with all the research, early access and leverage to get access to early treatments, and it puts us into that network. That strengthens everything from the top down so that the person who needs the protocol-driven chemotherapy can have it delivered in a level 3 hospital but at a standard delivered to 500 million people in the European Union. Is that it?

Dr. David Fennelly:

That is exactly the idea. To add to that, if we take for a second our poor prognosis cancers, and we are the national centre for pancreas cancer, a key strength of a national network that is linked with a European network is that our patients now are part of a large-scale European network of care. The ability to perform clinical trials, gain data and develop new treatments quickly is far stronger as part of a European network.

Pádraig Rice (Cork South-Central, Social Democrats)
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I thank Dr. Fennelly very much. The next slot is for Sinn Féin and Deputy Cullinane.

David Cullinane (Waterford, Sinn Fein)
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Obviously we need a new cancer strategy. The first thing we have to do is look back on the last strategy. I have a number of areas I want to focus on. I will start first with funding because over the course of five of the last ten years there was no dedicated new development funding for the cancer strategy. In fact, in last year's budget there seemed to be a departure, whereby there was no funding given, which may be an indication that national strategies will not receive development funding and that the money will go to the regions, but there is a lack of transparency in relation to it because we still cannot determine how much additional funding went into cancer services in the last budget. What is the view of the witnesses on funding a new national cancer strategy? What would it look like? How important is multi-annual funding and continuous development funding for any new strategy?

Ms Nikki Gallagher:

I thank the Deputy. We believe it is crucial. We believe there should be ring-fenced funding, starting with an injection of €20 million for the 2027 budget but then for the next five years €100 million should be dedicated to the strategy. We do not have answers as to exactly how it should be distributed but we need to make sure there is a commitment to multi-annual funding and that it is very much ring-fenced. I will bring in my policy manager, Ms Harte, on this now.

Ms Emma Harte:

One thing we can say is that we have a cancer policy that is pretty comprehensive but we do need ring-fenced funding to make sure that we have a protected resource to implement the specific activities that will lead to the outcomes. Sometimes, leading that to a regional funding pot puts those services at risk of not being funded because they are then competing with other regional priorities and services in the region. One example of that could be the acute haematology oncology service, which is a brilliant pathway for people who are going through cancer treatment to call up a dedicated nurse specialist who can help them sort out their symptoms. That means they get to avoid going into an emergency department, which is a wholly unsuitable environment for them as they go through cancer treatment. This is an 8 a.m. to 4 p.m. service, Monday to Friday, and it is still not fully staffed. If we leave it to the regions to have the staffing resource requirement for that, those positions are going to be competing with other services.

David Cullinane (Waterford, Sinn Fein)
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Okay. Time is very tight. The witnesses support development funding-----

Ms Emma Harte:

Of course.

David Cullinane (Waterford, Sinn Fein)
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-----that is multi-annual and ring-fenced and the figure is €100 million.

I want to go to Dr. Fennelly with data I received through a reply to a parliamentary question earlier this year. Obviously there have been improvements in cancer care. I acknowledge that as well. People are living longer and excellent work is being done. We have a lot of innovation and very good treatment. I am very conscious of all of that good work and the investments and rewards we are now seeing from that.

To give some of the data, 11,600 women did not have access to an urgent, symptomatic breast clinic within the target time in 2025. More than 6,600 urgent colonoscopies were late. Some 1,300 patients did not begin chemotherapy on time and 1,500 did not begin radiotherapy on time. In addition, 61% of prostate, 45% of breast and 39% of lung cancer surgeries missed the gold standard for the recommended timeframe. We are beginning to see a slip in some of those KPIs. From Dr. Fennelly's perspective, why is that happening?

Dr. David Fennelly:

I thank Deputy Cullinane for the question. There are two key issues that impact our cancer services currently. The first issue is the national radiology implementation plan.

This was part of the 2017 strategy. We are currently dealing with a lack of radiology resources. To come back to the breast cancer KPIs, both urgent and non-urgent, a very clear reason for that issue is the lack of access to mammography and Tru-Cut biopsy. The same issue applies in respect of colonoscopies. There is a lack of facilities and a lack of equipment. There are key issues that impact on our cancer patients. The first is the infrastructure, particularly in respect of radiography and diagnostics. The second is bed capacity. As clinical director in St. Vincent's hospital, I struggle every day to deal with the fact that we have huge volumes of patients attending our emergency departments. This puts on pressure. We routinely run at 120% of the hospital's capacity. I am faced with the challenge of deciding between admitting a 75-year-old who is on a trolley in casualty to a bed in the hospital and admitting a young patient of mine in Tullamore with a sarcoma, who I need to get into the hospital for timely chemotherapy treatment.

David Cullinane (Waterford, Sinn Fein)
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I will raise a related issue because Dr. Fennelly mentioned infrastructure. This committee and I have raised issues regarding equipment in hospitals. Imaging and screening equipment are obviously important. The data we have shows that a lot of the equipment is well past its sell-by date. That does not mean it is not working. It is just that its replacement date may have been 2022, 2023 or even earlier and the equipment has not been replaced. This means it can break down more often and may need more maintenance. There was also a lot of equipment that was not working or that was not fully utilised because we did not have the staff, whether radiographers, specialist nurses, consultants or whatever it might be. What is Dr. Fennelly's view on that? Are there issues with outdated equipment in his own group? Is new equipment needed? Is there equipment that is not being fully utilised because the group does not have the staff to make full use of it?

Dr. David Fennelly:

A number of factors contribute to the issue. Radiographer staffing is certainly a key issue. We currently have 17 funded posts that we have been unable to fill. That impacts on the service we can provide. We also lack key equipment such as CT scanners and MRI machines. There is certainly a need for investment in radiological infrastructure for both radiography and radiation oncology.

David Cullinane (Waterford, Sinn Fein)
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In recent times, the Minister and the HSE have put a lot of focus on moving to a seven-day week health service to expand access to hospitals, expensive equipment and so on. It does not make sense that we are not utilising hospitals at the weekend. Cancer care, screening and diagnostics are an obvious area to look at. Is that happening in hospitals? To what extent is it happening? Can more be done in relation to weekend access to reduce waiting times and make sure we are getting bang for our buck in light of how much this equipment costs in the first place?

Dr. David Fennelly:

We welcome the expansion of services to a six-day service. From an oncology perspective, I think it is fair to say that St. Vincent's hospital and many of my colleagues around the country already operate a six-day and weekend service. A key component in providing additional resources over the weekend is the support staff. That leads to pressures in terms of overtime payments and so on. There is no question but that, if we could provide those additional staff, it would allow us to extend capacity. We still require infrastructural support and funding for new capital spending on equipment.

Colm Burke (Cork North-Central, Fine Gael)
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I thank all of our guests for their contributions. Dr. Hofmarcher spoke about the cancer dashboard, which clearly sets out a number of key issues. One of the issues raised in the report is that, while we have really pushed forward on breast cancer, breast cancer still accounts for 18% of cancer-related deaths. We have done a lot but what more should we be doing? Why is the death rate in that area not reducing? Would the witnesses like to contribute on that issue?

Dr. David Fennelly:

Looking at the area of breast cancer throughout the country, I am happy to say that the standard of care is excellent from the perspectives of surgery, medical oncology and radiation oncology. The problems we run into relate to access to the service. By that I mean access to diagnostic equipment and to radiology. We have willing and able surgical and medical oncology workforces. I speak with my surgical colleagues regularly and they are incredibly frustrated by their inability to get patients through the diagnostic bottleneck, to get them mammography and Tru-Cut biopsy so that they can be diagnosed and proceed with definitive treatment.

Colm Burke (Cork North-Central, Fine Gael)
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The issue we are talking about this morning is the next ten-year strategy. The Department, the HSE and the people working at the coalface need to get together to plan this. I know there is a need to research what has worked, what has not worked and where vacuums exist. That all needs to be identified. However, at this stage, is it not essential for the Department to put together a group with the HSE to start looking at this issue rather than waiting for an analysis and not planning ahead? The Irish Cancer Society representatives might give us their views on that issue.

Ms Nikki Gallagher:

We think both are necessary. In a conversation in this room last month, the Department of Health indicated that the current cancer strategy will run until the middle of next year. We believe very strongly that the current cancer strategy still needs investment and support if it is to be rolled out effectively. That must happen in parallel with planning for the next cancer strategy. It is a ten-year strategy so it is really important that it is done correctly. Patients must be at the centre and key stakeholders must have a role and input in determining what the priorities are. However, it really must be funded. We really do need this commitment to multi-annual funding and development funding.

Colm Burke (Cork North-Central, Fine Gael)
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Is there a problem in that everyone is waiting for the Department to make a decision about the review and the forward planning? Should the people working at the coalface and the Irish Cancer Society not be pushing themselves to look at the issues to see where the vacuums are and to consider where we want to be in ten years' time as regards this issue?

Ms Nikki Gallagher:

From the conversations I have been having in the four months since I began in this role, I think the majority of stakeholders know what the key issues are. They know what has worked and they also know what has not worked and why it has not worked. There is a huge appetite among stakeholders to contribute to the next national cancer strategy. Everybody is very willing and able to do so when the opportunity arises. We are certainly going to continue advocating for the new strategy to be developed as soon as possible.

Dr. David Fennelly:

On the next national cancer strategy, I talk about a networked model of care. I assume that appropriately resourced infrastructure will form part of that. I refer to radiology and diagnostics. A networked model of care is undoubtedly the right way to provide excellence in quality of care for our patients and access to clinical trials. However, it does assume that we have appropriate numbers of scanners and MRI machines and adequate mammography facilities, PET-CT facilities and diagnostics from a pathology perspective. That has to be done in parallel.

Colm Burke (Cork North-Central, Fine Gael)
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There are eight centres around the country. At this stage, has there been engagement among those eight centres about what they want to do over the next ten years? Should that not start at this stage? Even if the Department is still not prepared to put the strategy group together, should the eight centres not be having this discussion about their priorities at this stage?

Dr. David Fennelly:

Again, I can only speak to my own centre but those conversations have started. They are very much active at the present time. We are engaging with the HSE. From a cancer perspective, I meet with the HSE regularly. I have also been in with the Department of Health to discuss this very issue.

Those conversations are happening. I am concerned about the budgetary structure because there is no doubt that a sequential process of cancer strategies over the past 30 years has been hugely successful. It has been directed by an independently funded national cancer control programme. That funding model is changed. The funding has now been devolved to the regions and that is not working for cancer care.

Colm Burke (Cork North-Central, Fine Gael)
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I also have the same concern as regards how the co-ordination among six regions is going to work. With cancer, there is subspecialisation, etc. How is that going to be co-ordinated? Has any kind of discussion taken place on that issue?

Dr. David Fennelly:

Discussion is taking place within the cancer centres. If I am to look at the structure and development of national and supraregional centres, much discussion has taken place between the different centres. We have talked with our colleagues in Waterford. We have also talked with our colleagues in St. James's Hospital in Dublin with regard to rationalisation and surgical centralisation. Those discussions are happening at a clinical level.

Colm Burke (Cork North-Central, Fine Gael)
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From a European point of view, what would Dr. Hofmarcher now prioritise? He has given a fairly comprehensive report. He has good knowledge of it. What would he prioritise over the coming ten years as regards getting a better delivery model in place?

Dr. Thomas Hofmarcher:

I also think the establishment of a national cancer network is a good approach, but it needs to come with implementation of standardised care pathways. This is something Denmark, which also has a regional cancer care system, spearheaded in 2007, almost 20 years ago. It was so successful that almost ten years later, Norway and Sweden took on this model of care. Even though there were regional systems and responsibilities, there was still an agreement to divide up the country, while at the same time making sure that no matter where someone lives in a country, they will be going through the same standardised care pathways. The same timelines apply, the same services are supposed to be provided and so on. However, this of course requires investment, as Dr. Fennelly said, to make sure there is enough capacity to provide the services in a timely manner, and that there is good co-ordination between the designated cancer care centres and the smaller local hospitals. There is a hub-and-spoke model. The co-ordination needs to be well developed to make sure that cancer care is not provided in isolation, but co-ordinated between centres in a predefined region.

Pádraig Rice (Cork South-Central, Social Democrats)
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I said at the start we have done a number of sessions on cancer services. We had a session last October on funding and one in April on radiation therapy. This is the third in that series. It was interesting that, following the committee hearing in April, the Government, in May, announced the implementation of a strategic infrastructure programme for replacement and expansion of public radiation and oncology facilities. That was the topic of our discussion in April. I understand a working group has been established since then. Have either of the witnesses received any updates on that work, or have they been asked to give input to that?

Dr. David Fennelly:

I cannot say I have, no.

Pádraig Rice (Cork South-Central, Social Democrats)
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Not yet. That is an issue we will follow up on with the witnesses because it is an important issue and we want to see progress on it. As I said, we had a dedicated session on that, and it is one we will return to. Hopefully, there will be some progress on it.

On the cancer dashboard and the Public Health (Alcohol) (Amendment) Bill, Ireland has performed worse than the WHO benchmark for alcohol consumption. The cancer dashboard report recommends intensifying public awareness campaigns, emphasising the health risks associated with alcohol consumption and strengthening enforcement of the Public Health (Alcohol) Act 2018 across all of its regulatory provisions. This might be a question for Dr. Hofmarcher. One of the provisions in the Act was on health warning labels on alcohol products. That has now been delayed until 2028. Does Dr. Hofmarcher think that was a mistake? Should the Government have moved ahead with that labelling?

Dr. Thomas Hofmarcher:

You have to think about the most effective measures that will impact on alcohol consumption. Labelling was tested on cigarette packages when it came to smoking. However, it has not really been tested on alcohol, at least not in European countries. The question is what difference it will make. Will it deter people from buying alcohol or are there other measures that might be more impactful? With cigarettes, as with alcohol, the most impactful measure is to increase excise. Of course, there is always the possibility of adopting several measures at the same time, but my concern is always what the most impactful measure to achieve the intended goal is.

Pádraig Rice (Cork South-Central, Social Democrats)
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My concern is that any of the implementation measures under the Public Health (Alcohol) Act have had pushback from the alcohol industry and lobbyists. Does Dr. Hofmarcher think the industry and lobbies have too much influence over health policy across Europe?

Dr. Thomas Hofmarcher:

The alcohol industry has a big influence, and it is much stronger in some European countries. We know that in France, the French winemakers are very much against any kind of labelling because they are worried it will affect their products. At EU level they will most certainly block any efforts to have standard labelling. Again, looking at the lessons from tobacco, what works best is increasing taxes.

Pádraig Rice (Cork South-Central, Social Democrats)
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There is a low level of awareness among people about the link between alcohol and cancer. What can we do to increase that awareness?

Dr. Thomas Hofmarcher:

In general, there is a low level of awareness. It is not at all at the same level as it is with cigarette smoking. It is important to increase that level of awareness. This is also why awareness of alcohol and its link to cancer was put into the latest edition of the European code against cancer, which was launched last year at European level. I still think this can help to reduce consumption but it might not be as helpful as other measures, such as increasing taxation on alcohol.

Pádraig Rice (Cork South-Central, Social Democrats)
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Does the Irish Cancer Society have any thoughts or reflections on those areas, or on any others? There has been pushback on alcohol advertising. I had a Private Members' Bill to limit alcohol advertising to try to enforce the Public Health (Alcohol) Act. It was opposed by the Government. We have seen at every step with the implementation of these public health measures that there has been resistance from either lobbyists, the alcohol industry or the Government. What is the Irish Cancer Society's view on that?

Ms Nikki Gallagher:

From our point of view, any and all measures ought to be mobilised. We believe strongly in education and making sure that people understand and are making informed decisions. Obviously, people can make whatever decisions they wish but they need to be informed. At this point, there is just too low a level of awareness of the link between cancer and alcohol. We are also talking about value for money and the reason we are talking about that is that sometimes when there is pushback, it tends to be framed in terms of damage to the Irish economy or the impact on the Exchequer. The more we can raise awareness and prevent cancers, the more money we save. That is obviously also positive for the Irish economy. It is important that these decisions are taken in the round. We believe all measures ought to be implemented to raise awareness. Anything we can do to reduce the incidence of cancer, we should do.

Pádraig Rice (Cork South-Central, Social Democrats)
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Does Dr. Fennelly have any thoughts on the measures in the Public Health (Alcohol) Act?

Dr. David Fennelly:

In Ireland it is a complicated problem. We always hark back to the cultural situation that exists in Ireland. I agree with Dr. Hofmarcher. If we speak nationally, the measures that have proven successful have been to raise taxes. Cigarette smoking is certainly an example of that. The problem with raising taxes on alcohol is that it is likely to hit a particular group very hard, and that will make it difficult to implement.

Education not only about the risks of alcohol but of the benefits of reducing alcohol consumption and of a healthy lifestyle is key, and at an early stage. This is a message we have got to get out to our school children because that is key to how we change behaviours in the future. That is really an effort. As the national centre for liver cancers, we are very much aware of that and education for our staff and patients is a very important part of that. With the Irish Cancer Society on board, that is something we should really be looking to do, namely to improve the educational aspects and target a younger population to try to get that message out there.

Pádraig Rice (Cork South-Central, Social Democrats)
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It is crucially important that we increase awareness about the harms and risks in relation to alcohol. There is not wide enough awareness across society, so it is an important one. Finally, in relation to the funding of the new national cancer strategy, the Irish Cancer Society looked previously at the last national strategy and the funding gap there and identified certain issues. Ms Harte might tell us about how much of a funding gap there was in the last strategy and indicate how much more funding needs to be provided for the next one.

Ms Emma Harte:

It is important to say that we actually have a good sense of what was invested, so we just need that number to be clear and transparent. When it comes to funding the national cancer strategy, as with funding healthcare in general, it is about having a really good sense of what things cost. Therefore, if we are setting out a policy and saying these are the activities we want to achieve, we need to fully cost them out. Then, we need to have an operationalisation plan that basically states what we hope to achieve in this timeframe and say here is the underpinning funding for that. We also have to ask how it links into other sectors, so where is the responsibility of other Departments for this all-of-government approach and what infrastructure investment do we need? These are some of the first-step questions we need to ask.

Pádraig Rice (Cork South-Central, Social Democrats)
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Maybe we can do that in a later round, if we have time. The next slot is an Independent one. I call Senator Clonan.

Tom Clonan (Independent)
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The witnesses are all very welcome this morning. I must apologise for not being here for their presentations. I was attending a committee meeting next door and I have to return to that committee, so I apologise in advance.

My beautiful older sister, Pauline, was two years older than me. I remember in the context of this conversation that she taught me how to smoke. I remember we were listening to "(Don’t Fear) The Reaper" by Blue Öyster Cult while she was teaching me how not to pass out while smoking a cigarette. She went on to develop breast cancer and from diagnosis to her passing was about 18 months. She was very unlucky. It was a very aggressive tumour. We went on that journey with her as a family. I cannot speak highly enough of the oncology team. She was treated in St. James's Hospital. They took every measure they could to support her, including psychological support. She had two small children. She knew she was dying. The care she received was absolutely excellent. In her last weeks, she contracted an MRSA infection. She was then at home receiving palliative care with the public health nurses calling in and helping her with her dressings for the MRSA. However, because of the support that she got, she was still that beautiful sister and mum. Notwithstanding all the challenges, she had a dignified passing. I joked with her and asked her if she remembered "(Don’t Fear) The Reaper" and she said, "Don't start; he's on his way". I just want to commend everybody in that regard.

I would say to my colleagues, particularly to my Government colleagues, that it is not useful or helpful to blame capacity issues in our hospital system on hospital doctors, consultants and clinicians. It is really unfair. It is very easy to do it but it has nothing to do with clinicians and it has everything to do with the Department of Health and the Minister, who is ultimately responsible. I am happy to say that my sister's eldest boy, who came home from school that day to see his mum passed away in bed, is now doing postgraduate medicine in University College Dublin, UCD, and notwithstanding the Minister's comments recently, I hope he does not go to Australia. I hope he makes a contribution here.

My principal question is for Dr. Hofmarcher. I wish him a good morning, although it is probably nearly afternoon in Sweden. We have had many presentations here from the National Centre for Pharmacoeconomics and I have questioned its representatives closely. In my previous life, I was an academic and supervised postgraduate and PhD and postdoctoral students and I was, therefore, very interested in the manner in which they conducted their pharmoeconomic research. On questioning, it informed the committee that their staff consists entirely of statisticians and so their pharmoeconomic analysis of drugs and interventions is an entirely quantitative exercise. Is that the case in Sweden? What kinds of disciplines would be involved in pharmoeconomic analysis?

Dr. Thomas Hofmarcher:

I thank the Senator for that question. At our equivalent, the health technology assessment, HTA, body, there are not just statisticians working there. In fact, there are health economists. Even former colleagues of mine are working there and they have studied health economics. They are also lawyers working there. When we want to make a comprehensive assessment of new cancer medicines, there are different aspects to consider, of course. We need statisticians to understand how to interpret the outcomes of clinical trials and the survival curves, if you like, in cancer trials. There are other considerations to be taken into account, including equity issues, for instance. Therefore, we try to look at the medicine assessment more holistically than only the numbers.

Tom Clonan (Independent)
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On that term "equity" that was used, do ethics play a component in the evaluation in Sweden? Does it have ethicists?

Dr. Thomas Hofmarcher:

It is not like people have this as a speciality but ethical aspects are part of the decision-making process as well. It states in the guidelines that they have to be obeyed. That can take expression when we are working with rare diseases or therapeutic areas where there is no other treatment available and then for ethical reasons, we might accept a higher price simply because it is the only option for patients, so that is taken into account.

Tom Clonan (Independent)
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It is my understanding that does not take place here and there is no ethical component or dimension to the evaluation of treatments, drugs or therapies.

In the pharmoeconomic assessment in Sweden, do people incorporate a qualitative dimension or phenomenological dimension to the analysis in terms of the impact of the provision or non-provision of a treatment therapy or drug impacts on a person's lived experience?

Dr. Thomas Hofmarcher:

That is also a good question. What we have tried to do in recent years, although not systematically, is bring in the perspective of informal caregivers at least. It is not necessarily how the patient is affected but how family members are affected and the time requirements from them. That is an aspect that also plays a role and new medicines can also make a difference for them.

Tom Clonan (Independent)
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It is interesting because yesterday I stood outside this Parliament with about a dozen young people with Friedreich's ataxia. I have to pay tribute to my colleague, Senator Teresa Costello, from Fianna Fáil who has been instrumental in getting treatment approved for Duchenne’s. These young people are begging for Skyclarys to be approved. My understanding is that has been shelved. When the whole world came to a halt to try to rescue some children who were trapped in a cave a number of years ago, if you recall, even Elon Musk got involved and here we have similar group of beautiful young people and there is no intervention, even though there is a treatment for them. I believe that is profoundly unethical and that our pharmoeconomic assessments were outliers in that regard.

I know that Ireland is an outlier in relation to the delay in having cancer treatments and therapies and innovations approved here. What would the witnesses say is the principal reason for that delay? Does the manner in which we assess things play a role in that?

Dr. Thomas Hofmarcher:

To be honest, that is a bit of a black spot.

Tom Clonan (Independent)
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I am sorry; I direct that question at Dr. Fennelly.

Dr. David Fennelly:

Yes, there is no question we are an outlier in that process with regard to drug approval and getting it through the European Medicines Agency, EMA. The process is that drug approval happens through the European Medicines Agency which then goes to the HSE. The HSE can then do a rapid assessment. If it is a costly drug, there is a health technology assessment. This is also run through the National Centre for Pharmacoeconomics. The problem has been that while there is a statutory limit of 180 days, which was established many years ago, over 85% of our medicines exceed that. That timeframe can run to over a year, so we are undoubtedly outliers in that process. We do not have a rapid access programme, which many European states have. The main goal of the process is to ensure cost -effectiveness, but that militates against rare diseases and orphan drugs and it really makes it very difficult for those drugs to get appropriate approval in a timely manner.

Tom Clonan (Independent)
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I thank Dr. Fennelly, and to Dr. Hofmarcher I say tack.

Teresa Costello (Fianna Fail)
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At the outset, while not related to this, I refer to a remark made by Senator Clonan. Skyclarys has not been shelved. If families are watching in, they might get a terrible fright if they hear it has been shelved; it has not. It is being reviewed by the rare diseases group. There should be some response back within the next three to four weeks.

I feel it is important to clarify that because there are some very distraught people out there and we do not want them in a worse state.

I am going to speak before asking questions. I am a breast cancer survivor and I was diagnosed in 2013. The day I went for my appointment, I had a triple assessment. As far as I can see, that is not happening these days. The girls who are part of my support group tell me that they are being sent away and told they will be given an appointment, and they could be waiting six months.

We constantly spread the message that early detection is key. We educate people. I am blue in the face telling people the eight signs and symptoms to look out for. When younger women do the right thing, present to their GP, are referred on and go to breast care, they are often sent away with the promise of a scan. Breast cancer, as everybody knows – I do not need to say it in this room – is extremely aggressive in younger women, more so than in older women. One of my concerns is the delay in diagnostics. I understand that capacity is an issue. It is staring us all in the face, given that one in two people will get cancer in their lifetime, if that is the statistic.

We are already behind the curve on this. My treatment in St. James's, up to this very day, has been excellent. I would not be here if it were not for the treatment I received. I am very grateful for that, but that does not mean I do not know when improvements are needed and things need to be reset and examined again.

I have concerns about the procurement of machinery because I think that is so concerning. If there is a photocopier in an office that is past its sell-by date, it is disposed of and a new one is obtained. In cancer care, this is life-and-death kind of stuff. I would be interested in the witnesses' opinions on that.

I am very concerned about education around the HPV vaccine. I feel so much good work was done but Covid-19 seemed to instil fear in people about signing their children up for the vaccine. We need education on this.

Sunbeds are a huge issue. They are everywhere. I do not believe children realise the real impact of what they are doing. As somebody who was very vain when I was younger, I believe a good visual education showing the not-so-pretty side of sunbeds is badly needed in our society. Children want to look healthy and good, but they do not realise the unhealthy things they are doing, such as using illegal weight-loss jabs. I am sure people are presenting with liver cancer from those. I would be surprised if they were not. There is also the issue of nasal tanners and such products, which are really out of whack.

I was really interested in the cancer network that has been spoken about. How would all of that feed into early-access programmes and clinical trials, linking us with Europe? How advantageous would this all be?

I have a huge problem with drug approval timeframes. In this regard, I refer to Skyclarys, Duchenne muscular dystrophy treatment and any rare disease and orphan medicine being approved. Approval is taking far too long and this is unacceptable. We have been talking about this for many years, but the time for change is right now, unless people want to be listening to me in the Seanad asking on a day-by-day basis what is going on and why things are not happening at a proper pace. It should not take 712 days to do anything. There is no defending it, no saying it is acceptable and no reasoning behind it. These matters have to be addressed. Additional staff have been allocated to the National Centre for Pharmacoeconomics, NCPE. We need to get the work done and have decisions made on the drugs.

On BreastCheck, I put in a comprehensive submission in 2022, I think, to have the age range for breast cancer screening expanded. I am nearly at the age for my free breast cancer screening. It should be from 40 to 75. Perhaps Dr. Fennelly could talk about the benefits, especially of early access.

Dr. David Fennelly:

I thank the Senator for the question. May I refer again to the south east, because I am the clinical lead for that area? The structures already exist. What I need to do with regard to the very issues the Senator spoke about, including access and rare diseases, is ensure that patients in my network have rapid access to the specialist centre. That is what a network will do. The additional funding I will need for this is €500,000. I am looking for additional clinical nurse specialists and some administrative backup. The centres, hospitals and specialists exist. What I am looking for is support to allow us to do our job.

I work with the breast cancer surgeons regularly. I have a superb group of breast surgeons. Ms Carroll, my business manager, can speak to the key performance indicators, KPIs. We have been very proud of our KPIs up until recently, but we are falling behind on the urgent and non-urgent ones. That is purely and directly related to access to mammography, so we need that to be addressed.

To me, however, that is slightly separate from the point on the network. A network ensures that a patient with a rare disease who turns up in Kilkenny, by attending his or her local hospital there, will have rapid access to the specialist centre. That will provide great comfort to the patient because, as soon as they are diagnosed, they will be linked with a clinical nurse specialist and have direct and rapid access to the centre of specialisation and the multidisciplinary team.

A treatment plan will be co-ordinated. A pathway that is benchmark-approved by the Organisation of European Cancer Institutes will be delivered locally in the patient's hospital. The key to that, particularly if the patient has a rare disease, is that if there is a clinical trial he or she can access, whether in Ireland or Europe, access can be given. That can be done in the local hospital. This is key to looking after the group of patients in question.

Triple assessment is vital. We need support. We need additional funding for capital investment, mammography machines, the ability to carry out Tru-Cut biopsies and our pathology services. Pathology services have expanded. We are now doing extensive genomic testing. Molecular pathology is an expanding area, and we need to be in a position to take advantage of that.

The Senator spoke about the HPV vaccine. I have been in this business for a long time and I have looked after many women who have died from cervical cancer. To see that and recognise that it is a preventable disease is tragic. Therefore, education is hugely important, in the same way as we referred to it in respect of alcohol a little while ago. It is about educating the right patient groups. We should not be afraid of educating our young people about this. We have a disease that we will eradicate. HPV vaccination will also affect head and neck cancers, so the impact will be enormous. We cannot let the small group of people who are against this process stand in the way.

Pádraig Rice (Cork South-Central, Social Democrats)
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I thank Dr. Fennelly.

Teresa Costello (Fianna Fail)
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Can I comment?

Pádraig Rice (Cork South-Central, Social Democrats)
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We are over time, but we can come back to it. Our next slot was to be a Sinn Féin slot with Deputy Sorca Clarke. She sends her apologies. She is unwell today, so she is unable to attend. The next slot is that of Fine Gael, so I call Senator Boyle.

Manus Boyle (Fine Gael)
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I thank everybody for attending. I am really heartened by what Dr. Fennelly is saying about regional centres. As he knows, I am based in Donegal, in Letterkenny. Thankfully, we have Galway as one of the centres of excellence. I must say that anybody I talk to is more than happy with Galway, but the biggest problem for us in Donegal is travelling down. Patients cannot really travel for four hours for treatment and backup. The regions need to be more involved.

Dr. Fennelly spoke earlier about clinical trials. How does he propose to get the regions more involved in clinical trials? It seems that if we can get the information and circulate it, we can get movement and diagnosis. How does Dr. Fennelly intend to achieve this?

Dr. David Fennelly:

Clinical trials come in a variety of different types, such as surgical clinical trials, medical oncology clinical trials and chemotherapy clinical trials. From a surgical perspective, with surgical centralisation, there are some patients from Donegal who will still need to travel to the specialist unit for their surgery. However, for a chemotherapy study, be that an adjuvant breast study or an adjuvant colorectal study, there is no reason with a network structure that the patient cannot go back to Letterkenny and receive their treatment locally. The treatment that they would get would be co-ordinated from the local hub from the regional cancer centre. That treatment could be a standard treatment pathway, which would be OECI benchmarked and approved as state-of-the-art cancer treatment throughout Europe, or a clinical trial, which is co-ordinated through investigators who are based in the regional cancer centre.

I recognise that somewhere like Letterkenny and Donegal poses significant physical and geographical challenges for our patients. We need to look at those areas with a special focus. In my time, I have looked after many patients from the Donegal area who travelled back and forth to Dublin. While they were quite happy to do it because they were getting access to a specialist unit, the travel time involved took a toll on them and their quality of life. As I talk about a national network, I would love to see an all-island national network incorporating my colleagues in Belfast, many of whom I know. There is no geographical reason that cannot be done. Again, I can see obvious benefits, particularly for areas in the north west, from a closer alliance with them. We already see this happening in children's care, in heart disease and in heart surgeries. Our cardiac surgeons travel across the Border to do surgeries in the North. I see no reason that cannot be extended to other areas.

Manus Boyle (Fine Gael)
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I totally agree. Even last week, I had a man come in who is attending Galway hospital for prostate issues. He had to make four trips to Galway to start off, to get inducted and to go the whole way through. He asked me whether there is a new therapy out there. Is it called LRLT?

Dr. David Fennelly:

Radioligand therapy.

Manus Boyle (Fine Gael)
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Yes. That would come on and help. It could be there in Donegal rather than travelling up and down for all this treatment.

Dr. David Fennelly:

Radioligand therapy is a very exciting new therapy. We are a national centre for peptide-related radiotherapy, PRT, which is sort of a cousin, if you like, to radioligand therapy. We have the infrastructure that can deliver that treatment. Delivering that in a networked fashion will be difficult. There will be significant infrastructural challenges to doing that. I would like to see a national programme that would allow the development of radioligand therapy and then a plan in terms of how to deliver it on a national basis.

Manus Boyle (Fine Gael)
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I was just wondering when it came up.

There is a big problem with the delay in drugs. It has to go through this whole system. We saw it with finasteride lately. If Europe adopts these medicines - we are all part of Europe - should we not be doing the same here? It seems that Europe adopts it and maybe two years down road we come in and think about it and then it is put on the list. It takes so long to get any movement on this. Surely we should have some kind of European rules that provide if it is adopted in Holland and Germany, we should fast-track it too.

Dr. David Fennelly:

We would like to see that. Dr. Hofmarcher may wish to comment on this. Drugs approved by the EMA go through a separate process here nationally. They are referred to the HSE and then they go through the National Centre for Pharmacoeconomics. This has been the focus of a lot of work over the past number of years. There is a statutory limit of 180 days. There is a target of ensuring all drugs are approved within 180 days by 2029. I would certainly like to see a much more rapid framework for those drugs once they are approved by the EMA. The focus of our assessment here is not around drug efficacy, but its cost effectiveness. That is what is leading to the delays in drug approval.

Manus Boyle (Fine Gael)
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One of the biggest problems I would see in Donegal is that once a person is diagnosed, it takes so long to get movement. People are asking for representations to try to get people moved up a list or whatever. There should be a rapid process when they are diagnosed. It should be about doing A, B, C and D to ensure they get what they need. That has to be moved along. I know people who are waiting six, eight or ten weeks to start treatment. One woman said to me, "I just want it gone." That is eight or ten weeks of that poor woman's life. It is heartbreaking when one listens to her. All she wanted to do was get it out, but it is all about delays. They will get so far, but if the consultant is not on that day or there is a clinical nurse or another staff member off, it puts it back again. That is something that needs to be included in a new strategy. Once a person is diagnosed, there should be rapid access the whole way through.

Regarding the machinery, I talked to Ms Gallagher at a previous meeting. The Irish Cancer Society is doing great work. Regarding scanners and everything like that, our infrastructure needs to be upgraded immediately. By right, we should have top-of-the-art stuff. Whatever the best thing is on the market should be in Ireland.

Dr. David Fennelly:

The network structure will deal with that issue of access. What I talked about with regard to the south east I would extend to the north west as well. The addition of clinical nurse specialists - I call them "nurse navigators" - would reach out to these patients. Once a diagnosis is made of a patient in Letterkenny or wherever, they will have immediate contact with a clinical nurse specialist, a trained specialist and a nurse navigator, who will provide rapid access to the specialist centre. That does two things. First, it provides rapid access to the specialist multidisciplinary team. Second, it reassures the patient because the patient now has a contact person, and they know exactly where they are on that pathway. That is a key part of a functioning cancer care network.

Manus Boyle (Fine Gael)
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Definitely.

Pádraig Rice (Cork South-Central, Social Democrats)
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I call Deputy Cahill.

Michael Cahill (Kerry, Fianna Fail)
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I welcome our witnesses, and I thank them for their presentations. I am going to speak specifically about my own county of Kerry and the plans that are there to build a new oncology and haematology unit. The existing unit treated over 5,000 patients last year. Kerry patients are mainly travelling to Cork, Limerick, and indeed, Dublin for treatment. We have an amazing committee in Kerry called Comfort for Chemo Kerry. It has raised almost €2 million. It is on a long journey. It is going on for quite a while. I would like to see it progress. I am informed by management in the HSE and in University Hospital Kerry that it is to be part of the new 96-bed block in the University Hospital Kerry. We need to move that forward. It is only right and proper that we have a purpose-built stand-alone facility where Kerry patients can be treated with dignity and respect. It is hugely important. I cannot stress it strongly enough about being able to have treatment and chemo in close proximity or as close as possible to where the patient lives. We have three peninsulas in Kerry. It is a huge county. It is important that our people get the best of services and all of that.

A colleague rang me yesterday. He had been to hospital yesterday morning. He was in trouble. He has been diagnosed with stage 4 cancer. We had a good chat about the journey ahead. Two days previously, I was speaking with another friend of mine. I was inquiring because I had heard something about his brother. He has also been diagnosed with stage 4 cancer. I am aware that it happens to one in every two people. That is a staggering and frightening statistic. It is important that we have the best of services for our people and make the journey as easy as possible. It is a difficult road, as we all know only too well.

My wife had a niece. She was in her early 20s when she died. She was married with a child. She had a sister who was in her early 40s. Prior to that, her eldest boy, who was only four and a half, also passed. We all have family, friends and neighbours. It is important that we put our shoulder to the wheel.

If possible, I would like to put in a request, to be considered in due course, for that organisation in Kerry to be invited to a meeting of the committee in order that we can hear from its representatives. The new mayor of Kerry, Mikey Sheehy, son of the famous Mikey Sheehy who played for Kerry, is very much involved with that organisation. He is a survivor. It would be worth the committee's while to listen to details of the organisation's story and journey and help it any way possible. It would also be good to hear from similar organisations throughout the country.

Pádraig Rice (Cork South-Central, Social Democrats)
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Do any of the witnesses wish to respond to any of those points?

Dr. David Fennelly:

I completely agree. While I would absolutely endorse providing chemotherapy services at University Hospital Kerry, I would want to ensure that they are approved by the OECI and benchmarked against best European standards. I would also want to ensure that patients in Kerry who were receiving their treatment locally had access to any clinical trial activity that was available. That is what a network will provide. Rather than detracting from local services, it should enhance and support them.

Ms Emma Harte:

I will contextualise the challenge ahead. I am very sorry for the Deputy's losses. We know that today we are not meeting the need of all the people who need to come in to services. Those services should be delivered at the right time and in the right place. The scale of the challenge ahead is that by 2045, there will be a doubling of cancer diagnoses compared with 2015. What the next national cancer strategy should do - and what we should be planning for beyond the next national cancer strategy - is to consider how we are able to ensure that the need coming down the tracks can be met. That is just one point that we need to consider, moving forward.

Senator Costello made a point that I was hoping to address. It relates to breast cancer services. By 2045, 63% more people will be diagnosed with breast cancer than in 2015. Currently, we are not meeting the need for people to get through the diagnostic pathways. There is a right-now problem and there is a tomorrow problem, and we have to be able to address both. Part of that is looking at the infrastructure and looking at our workforce capacity, making sure that our hard-working workforce has the support that it needs. It is also about looking realistically at what things cost, moving into the future.

If more people are going to be diagnosed with breast cancer in the future, it means we need to expand our screening capacity. In the next ten years, approximately 800,000 women or more will be eligible for BreastCheck. How are we going to increase our BreastCheck capacity to ensure we have the staff and infrastructure to meet that need? The same is true of the symptomatic route. How are we going to ensure that we have a diagnostic pathway that is fit for purpose to meet the needs of all those women?

Pádraig Rice (Cork South-Central, Social Democrats)
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We have some time for additional questions if any members would like to come in for an additional round.

Martin Daly (Roscommon-Galway, Fianna Fail)
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I will follow on about the ageing demographic. We have explored the networks well and have made the point. We, as politicians, will be driving it along. We can see the benefits that would bring. People buy into the idea of local, accessible, protocol-driven, evidence-based, European Union quality assured care in their local hospital. That is for chemotherapy. We know that not everything can be provided in local hospitals.

I have come from a meeting of the disability committee. The excellent Dr. Martin McMahon and Professor Mary McCarron were talking about ageing and the challenges relating to disability. Professor Rose Anne Kenny was before this committee a couple of weeks ago talking about the ageing demographic. We are going to have 1 million more people over the age of 65 by 2040 and 1 million over the age of 65 by 2030. Cancer is a disease of old age. We hear all these terrible stories about young people getting cancer but, by and large, when you get older, you are more at risk of getting cancer.

Coming back to prevention, I will turn to Dr. Hofmarcher. I was taken aback by some of the figures on the cancer dashboard, especially around tobacco. We certainly congratulated ourselves when Deputy Micheál Martin brought in the ban on tobacco in the workplace. It was a pioneering move. Why are we so far behind on those preventative indices, including in respect of alcohol and tobacco consumption? Is there a reason for it? Has Dr. Hofmarcher any idea? Are there any data in that regard?

Dr. Thomas Hofmarcher:

When it comes to tobacco, Ireland has made enormous progress, because the rates have decreased from very high levels in the 1990s to much lower levels now. Ireland was ambitious in putting in measures and banning smoking in certain places and increasing taxes. It has been helpful. It is also fully aligned with international recommendations on how to approach tobacco control. Then again, the target is defined when it comes to tobacco consumption. It is to lower the prevalence to less than 5% in order to achieve a tobacco-free generation. It sees that despite the current measures, there is still a long way to go to achieve those targets. Looking at what has been accomplished over the past 30 years, those measures have had the intended effect. Continuing on that path is very important.

Martin Daly (Roscommon-Galway, Fianna Fail)
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A volume of disease is going to come. No matter how much money we invest, we are simply not going to have the capacity. People are living longer. Professor Rose Anne Kenny made the point that we really need to be considering public health programmes for smoking that start when people are in their 40s and 50s. How does Dr. Hofmarcher feel about the proposed generational smoking ban in the UK?

Dr. Thomas Hofmarcher:

I am aware of it. More countries are considering it. New Zealand and Denmark were looking this option of simply banning sales to younger generations. It is, in the end, a political question as to how much should be decided at a political level and how much freedom there is for individuals to make their own informed choices to take up tobacco smoking. Of course, if the only consideration is from a public health perspective, an outright ban meaning that younger generations would never start smoking would be the best.

Martin Daly (Roscommon-Galway, Fianna Fail)
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There are hugely powerful lobbying forces in the tobacco industry. They have tried to circumvent public health policy by bringing in new products, including vapes and tobacco bags, which were apparently being provided for free outside Croke Park last weekend. The alcohol industry is also a powerful lobby. That is going to be a major challenge.

I will return to digitalisation.

We really are so far behind the European Commission compass target of 2030 of every European Union citizen having access to a fully digitalised health record. I know I sound like a broken record, but I am going to say it again: when we look at the graphs, we cannot find Ireland because we are so far off the charts. We talk about networks and integration. Dr. Fennelly talked about collaboration, cohesion and integration. How can we deliver principles like that in healthcare delivery unless we are fully digitalised?

Dr. David Fennelly:

I thank the Deputy for the question. It is a huge challenge. From a local perspective, we have sought to develop digital systems and integrate systems within our cancer centre. When we underwent our Organisation of European Cancer Institutes, OECI, review, we were criticised, rightfully, in terms of IT infrastructure. It was commented that we were 20 years behind Portugal. This is a major issue for the Department because we do need significant investment to bring the IT infrastructure up to a reasonable level. The current projections for electronic healthcare records are that they are anything between seven and ten years away. That really is too long. We cannot wait that long. European legislation that is coming in will entitle all patients in Europe to access to their medical records. We are nowhere close to that space. Again, for the proper functioning of a network - I think we are all agreed a network structure is the way to deliver cancer care into the next decade - it has to be underpinned by an adequate IT infrastructure that allows us to capture data. As I commenced my role as clinical director, one of the first things I was seeking to do was demonstrate survival data, follow-up data and outcome data. Without that type of data, not only can we not measure our performance and audit it, but we cannot project into the future as to what our requirements will be. That is a very important part of the process over the next number of years.

Martin Daly (Roscommon-Galway, Fianna Fail)
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Judging by committee meetings in which we have spoken to the Minister, Deputy Carroll MacNeill, she is fully committed to this digitalisation project, as is the Secretary General, Mr. Derek Tierney. He has reiterated his support and commitment to this, as have the HSE and the Minster, Deputy Chambers, in terms of the funding of it. We can continue to throw money at our health service but unless we have the infrastructure and digital infrastructure right, we are going to be wasting money and we are not going to achieve maximum productivity. I thank the witnesses for their evidence.

Colm Burke (Cork North-Central, Fine Gael)
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I wish to ask Dr. Hofmarcher about screening. He made a big issue of this in his report. We have made a lot of progress in the area of screening, but Dr. Hofmarcher referenced two issues, one of which is relates to the uptake, especially with regard to bowel screening and how it is only 42% of men. Among people coming from lower educational attainment, we also seem to have lower figures of people availing of the screening programme for bowel cancer, breast cancer and cervical cancer. What have other countries done to get more people to take up the option of going for screening? What do we need to do in the next ten years about that whole programme?

Dr. Hofmarcher raised the issue of lung cancer screening. There is a pilot project, to which he referred. Has this been rolled out in other countries and how has it worked out?

Dr. Thomas Hofmarcher:

I thank the Deputy for those questions. When it comes to screening, there is so much potential to make sure that patients have a much higher chance of survival. The participation rates in Ireland are fairly good for breast cancer and cervical cancer but they are not good for colorectal cancer. In addition, there is this gradient by level of education whereby highly educated people are more likely to participate and people with a lower level of education are less likely to participate in screening. These are patterns we have also seen in other European countries, but several other European countries simply achieve higher participation rates. One lesson from more successful countries is to make sure that access to screening is as easy as possible for eligible people. In Sweden, we have struggled with our immigrant populations, who are not participating to the extent we want them to participate. For instance, for cervical cancer screening, we have switched to sending out self-sampling kits to people's homes so they can take the test at home instead of coming to a clinic to get the examination, which might be afflicted with stigma, so they do not want to do it in that way. The self-sampling has really helped us to improve the participation even in hard-to-reach population groups. The same goes for breast cancer, where instead of having women come to clinics, using mobile trucks to get the screening to women has also been successful. It simply makes it easier for women to overcome this barrier they are facing to participate. Likewise, the way we test for colorectal cancer screening is very important. Successful countries have started to simply send out self-sampling kits to all eligible people to facilitate the uptake because then they can test at home. They do not need to come to a clinic. It makes life a lot easier and has proved successful.

Many countries have piloted lung cancer screening. One country, Croatia, has already implemented lung cancer screening nationwide since 2020, with very good results that have been published. More and more countries are doing it and more are now at the brink of going from these regional pilots to nationwide implementation. The science is already there; it works. In the end, it is again a question of capacity. Are there enough radiologists and a human workforce available to perform the tests and follow up on those tests in a timely manner? It is no use trying to detect lung cancer early and have people get the diagnosis if they then have to wait for a long time to get treatment. Again, the capacity issue is very important, as is the stigma component for lung cancer screening. There it is a good example from the UK, where they also use mobile trucks to bring the screening to people instead of having current and former smokers come to a clinic because that does not work in many cases.

Colm Burke (Cork North-Central, Fine Gael)
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Okay. Dr. Fennelly might also comment on the issue of screening.

Dr. David Fennelly:

We are fortunate in Ireland in that we have had good screening programmes for a variety of the larger volume cancers. Education and capacity are key. Again, if I speak to our current issue, we house a national screening programme on bowel cancer on site in St. Vincent's UCD Cancer Centre, but the space and the allocation of time compete with our other national designations in terms of specialty sites. We are also the national centre for cholangiocarcinoma. That requires considerable endoscopy expertise. As we provide a natural service, that obviously competes for space for the screening programme. Again, it comes back to capacity. We have the healthcare professionals. We have dedicated clinicians who are willing and able to provide the service. We just need the support with the infrastructure to allow us to do that.

Ms Nikki Gallagher:

Could I-----

Colm Burke (Cork North-Central, Fine Gael)
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On the education side, can I ask about getting information out? Could a lot more be done in that area?

Ms Nikki Gallagher:

Yes, but I might just come back to the screening, if I may, for a moment. As the Deputy may know, the Irish Cancer Society was one of the funders of the Beaumont-RCSI lung health check pilot scheme. The results are phenomenal. We have some results in already. Through working with local GAA clubs and local doctors, they were able to identify a significant cohort of people who are at risk. Of the people they screened, 33 lung cancers were detected. Ten of those people have already had curative surgery. They were detected at stage 1. That is almost never heard of. The team in Beaumont is finalising some of the outcomes and the results right now. We would welcome the opportunity to bring those to the committee at a later date, if at all possible.

To the Deputy's second point on education, I completely agree with him. I am quite concerned. We are talking about older demographics. I am quite concerned we will miss a cohort here of young people for whom cancer seems to have gone over their heads because they were not part of the smoking generation. We are seeing young people who are not taking up human papilloma virus, HPV, vaccines, who are vaping, who are using sunbeds and who do not understand the cancer risk for alcohol. We need to be careful that we do not miss those in the next cancer strategy because they are not on the radar at the moment. Unfortunately, if we do not address this, they will be. We need to engage with young people where they are. It cannot be us, or the State, going out and telling young people what they need to do. We need to have proper communication programmes and engagement programmes to educate them about the risk in a way that we get them to buy in.

The Irish Cancer Society is also doing another pilot programme, with Trinity-St. James's, on young onset cancers. We have invested approximately €4 million in this programme where we are helping identify people who have young onset cancers, gastrointestinal, GI, cancers, and head and neck cancers. We are funding nurse navigator posts in that pilot programme and we would love the opportunity to come back and tell the committee about that as it is moving forward. We have to be careful that we are not missing a cohort and that we are engaging with them in an effective way.

Pádraig Rice (Cork South-Central, Social Democrats)
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I thank Ms Gallagher. I have a few additional questions as well and we will conclude after that. I want to tease through Dr. Fennelly's piece around the networks and the difference between the current eight cancers centres and the networks. In practical terms, what would be the main difference if you were contrasting the two models?

Dr. David Fennelly:

A big step forward was the establishment of eight designated cancer centres. Those cancer centres exist and continue to function to a high level. What a network will do is overcome the postcode lottery nature of cancer care. If you attend one of the eight designated centres, you get very high quality care. What I need to ensure with a network structure is that cancer care delivered at a high level in the cancer centre is extrapolated out throughout the network and that is where the network structure comes in.

Pádraig Rice (Cork South-Central, Social Democrats)
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Is it at one's local hospital? Could it be primary care centres-----

Dr. David Fennelly:

Yes.

Pádraig Rice (Cork South-Central, Social Democrats)
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-----purpose-built centres or what is Dr. Fennelly thinking in terms of that network? What would it look like?

Dr. David Fennelly:

We are building on existing structures. If I come back to the south east, because I am conscious of sticking to my area, I have gone to visit the local hospitals. We have been to Waterford and to Wexford. I have visited community intervention teams. The idea would be that a treatment pathway co-ordinated centrally in your hub is delivered throughout that network so a patient will go to Kilkenny, they will receive their treatment in Kilkenny and their follow-up - their intervention - will be through a local community intervention team avoiding the need for them to come back to the cancer centre. That builds on the structures that are already in place. It builds on the structures - the eight designated cancer centres. It is complementary to that.

Pádraig Rice (Cork South-Central, Social Democrats)
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It is a further outreach of the services. They are closer to people according to that Sláintecare principle of right care, right place, right time.

Dr. David Fennelly:

Exactly.

Pádraig Rice (Cork South-Central, Social Democrats)
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It is nearer to people while maintaining the high quality of the care and the high standards.

Dr. David Fennelly:

A key additional component - it is really important - is access to clinical trials. We lag behind the rest of Europe in terms of patient access to clinical trials and that is one thing that we really need to work on in the next strategy, namely to improve that to more than the 10% number that is the target.

Pádraig Rice (Cork South-Central, Social Democrats)
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Dr. Fennelly is piloting this in the south east. Is there an ongoing evaluation or is it evaluated at the end?

Dr. David Fennelly:

The Department of Health is actively engaged in this process and we have worked with the EU comprehensive cancer care networks, EUnetCCC, team. There is a number of centres that are looking at signing up and may also run pilot studies.

There will be a three-year period to evaluate this and then review.

Pádraig Rice (Cork South-Central, Social Democrats)
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Would you have one of these EU certified comprehensive cancer care centres in each of those networks?

Dr. David Fennelly:

Yes.

Pádraig Rice (Cork South-Central, Social Democrats)
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Very good. It is an interesting model. A lot of issues that are raised with us are around that access to care locally. Some of the members raised it in terms of their geographical areas and people having to travel, and having to be supported in travelling, and people who were ill getting treatment. It is a burden when they have to travel to get care and if that can be delivered at a high quality closer to home, it will definitely lead to better outcomes. It certainly is interesting. Hopefully, it will be an interesting feature of the cancer strategy and one for the Department and the HSE to look in more detail at.

The other piece I wanted to touch on was the HPV because we did not discuss it too much this morning. My understanding is the goal is to eliminate cervical cancer in Ireland by 2040 with the WHO defining the elimination of cervical cancer as fewer than four cases per 100,000, making it a rare cancer. Ireland's incident rate is currently ten per 100,000. By 2030, the goal is to reach 90% of HPV vaccines in girls by age 15. Are we on track to reach that target?

Ms Emma Harte:

This is a brilliant action plan. It is extremely ambitious but absolutely achievable and realistic if the vaccination rate can get to that point. The trend that we have seen over the past number of years is that the rate is around the three and four mark. We can do better. We know we can do better. We have done better.

Not only is this really important for eliminating cervical cancer but, as Dr. Fennelly said earlier, it eliminates other HPV associated cancers so already you are reducing potentially an incidence rate of 600 cancers a year to a handful. That is absolutely remarkable. We should be putting every effort behind ensuring that we can increase the uptake rate.

Pádraig Rice (Cork South-Central, Social Democrats)
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Is there any progress on reinstating the Laura Brennan HPV catch-up programme to those under 25 who may have missed it in school?

Ms Emma Harte:

As the Cathaoirleach will be aware, that is a key call from us and from other advocates out there. What we know is that in this academic year the vaccination is open to first years. That is the standard approach in the schools programme. However, it is now open to fifth and sixth years and next year it will be open to second years. That is brilliant. We really welcome that. In particular, many fifth and sixth years will be of the age where they can consent on their own behalf as well.

To the Cathaoirleach's point, we absolutely would love to see the Laura Brennan HPV vaccination catch-up programme be reinstated. The National Immunisation Advisory Committee, NIAC, body made a recommendation that the HPV vaccination should be available to people of all genders aged 24 and younger. We believe that evidence-based approach should be funded because it is quite expensive for people to pay out of pocket and it would be great for them to have a second chance at vaccination.

Pádraig Rice (Cork South-Central, Social Democrats)
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In relation to cervical cancer, Dr. Hofmarcher mentioned self-sampling. Is that something that we should be doing? In relation to sexual health, the self-sampling at home has been transformative in terms of people accessing tests at home and stuff like that. It is an innovation that maybe could be looked at.

Ms Emma Harte:

The screening service is looking at that right now.

Pádraig Rice (Cork South-Central, Social Democrats)
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Okay. It is one that is being committed. Are there any thoughts in terms of the HPV before we conclude?

Dr. David Fennelly:

As I said, the tragedy with this group of patients is they tend to be young women who suffer with this disease. The value of the HPV vaccine is indisputable because it protects a young group of women. Certainly, I would be very keen that an outcome of our next strategy, or a key part of that strategy, would be a major focus on education across these various areas that we have raised today.

Pádraig Rice (Cork South-Central, Social Democrats)
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The tackling the misinformation and the disinformation around vaccines is crucial.

I thank everyone. There was a lot in that session - lots of different pieces that need to be put together.

That is a reminder of why it is important to have a comprehensive strategy that ties the various elements together and that it is funded and resourced. It is important that we get a good evaluation of the previous strategy, that we get full resourcing for the next strategy and get it implemented in full, with full innovation and learning from our international partners as well as the ideas being proposed domestically, and that we collectively make progress and get cancer front and centre again on the political agenda and in terms of the health services. Working collectively we can do that. For our part on the committee, we are happy to continue to raise these issues, put a spotlight on them and focus on them. If we can help advance issues at all, we will try our best to do that. There are a number of members quite keen to see progress. It is an interesting time with a new strategy. Hopefully this session and the other one will have had an impact on that.

I thank each participant for their time and consideration. I know a lot of preparation goes into sessions like this and we really appreciate all the witnesses who come before us for the effort they put in, preparing and for answering a wide variety of questions that can sometimes come from left field. I thank to Dr. Thomas Hofmarcher in particular, who has joined us online from Sweden for the full session, for all of his work on the dashboard, which is very useful and very accessible.

I want to thank our colleagues from the Irish health service, our colleagues internationally, and the Irish Cancer Society, for their time this morning. We will address these issues again.