Tim O'Malley (Limerick East, Progressive Democrats)

I apologise on behalf of the Tánaiste who cannot be here as she has a prior engagement.

I move amendment No. 1:

To delete all words after "Dáil Éireann" and to substitute the following:

"commends the Government for the significant increases in investment in cancer services, in particular the development of services for women with breast cancer and cervical cancer, and supports the Tánaiste and Minister for Health and Children in her commitment to further develop cancer services nationally."

There have been significant increases in investment in cancer services since 1997. In parallel, we have also seen major improvements in cancer across all modalities of care, specifically medical oncology, oncology surgery, radiation oncology and supportive care.

Overall relative survival from cancers increased for men and women between 1995 and 2002. With regard to women, there were increases in survival of the four most common cancers: breast, lung, colorectal and lymphoma. With regard to men, survival improved for almost all cancers, notably for cancer of prostate and stomach, as well as lymphoma and leukaemia. By far the best survival rate for the commonest cancers was for female breast cancer. The overall true risk of developing cancer, allowing for the effects of population changes and ageing, is not increasing for women and is increasing by only 0.6% for men. The true risk of dying from cancer is decreasing by about 1% per annum. We have seen a substantial increase in oncology related activity in hospitals. The number of patients with a diagnosis of cancer rose from 58,000 in 1998 to over 80,000 in 2002. The number of day cases increased by 68% between 1998 and 2002.

International evidence demonstrates the proven efficacy of population-based screening programmes that are effectively managed and meet quality assurance standards. The Tánaiste is fully committed to implementing screening programmes which have proven efficacy in line with best international standards. The European Commission's recommendations on cancer screening were adopted by the European Council in December 2003. These recommendations proposed that screening tests which have demonstrated their efficacy should be seriously considered, and that the decision to implement such programmes should be based on available professional expertise and priority setting for health care resources in each member state. Population-based screening programmes for breast and cervical cancer have been proven to reduce mortality, with subsequent improvements in population health in terms of survival, morbidity and quality of life. Screening aims to improve survival from cancer, limit morbidity from cancer and improve the quality of life of those who have developed cancer.

I am pleased to have this opportunity to outline the considerable investment that has been made in recent years in the national breast screening programme and the Irish cervical screening programme. I take this opportunity to set out the current position on the development of these services nationally. The extension of the current breast screening programme to the remaining counties in the country is a major priority in the development of cancer services nationally, as is the extension of the pilot cervical screening programme. The Tánaiste has committed to making sure that BreastCheck will be available to women in all parts of the country. I am confident that during 2007 screening will commence in the western and southern counties.

BreastCheck, the national breast screening programme, commenced in the eastern, north-eastern and midland regions in February 2000. Screening is offered free of charge to women in the 50 to 64 age group in these regions. From the commencement of the screening programme to September 2004, 167,000 women were invited for screening and 120,000 women availed of the service. Under the national expansion, all women in the relevant age group will have access to breast screening and follow-up treatment, where appropriate. It is estimated that the cancer detection rate is approximately 7.8 per 1,000 screened and to date over 1,000 cancers have been detected. Screening uptake among eligible women is almost 77%, which is in excess of the 70% required to reach the target of reducing mortality by 20%.

The expansion of the BreastCheck programme to counties Carlow, Kilkenny and Wexford is under way. Screening commenced in Wexford in March 2004. BreastCheck expects to commence screening in Carlow in April this year and screening will follow in County Kilkenny when the first round screening in Carlow is completed. There are approximately 18,000 women in the target age group in the south-eastern area.

The national roll-out of the programme required detailed planning for the development of essential infrastructure to provide for two clinical units, one in Cork and one in Galway. This detailed planning involved considerable work by BreastCheck, University College Hospital, Galway, the South Infirmary-Victoria Hospital, Cork, and the Department of Health and Children. There are approximately 130,000 women in the target population for screening in the southern and western regions.

The planning of two static clinical units necessitated the establishment of two capital project teams to develop briefs for the construction of the two units. The former Western Health Board prepared detailed option appraisals for the BreastCheck development at University College Hospital, Galway. The brief proposals, with cost and phasing options, were then submitted to the Department for consideration. After careful evaluation the most appropriate option was selected. The South Infirmary-Victoria Hospital considered it necessary to commission a site strategy study to ensure the integration of the breast screening service into the present and future developments at the hospital. The Department made a capital grant of €230,000 available for the study to be undertaken by professional architectural, engineering and quantity surveying experts. This study was completed in mid-2004 and brief proposals were submitted to the Department.

After the evaluation of both briefs the Department was in a position to determine the capital funding requirements for the progression of both developments. These requirements were considered in the context of the overall capital investment framework and in September 2004 approval for a capital investment of approximately €21 million was given for the construction of the units. This investment will also provide for the mobile units which will be available to screen women throughout the country.

Subsequently, discussions took place between BreastCheck, the South Infirmary-Victoria Hospital, the former Western Health Board and the Department in regard to design issues surrounding the development of the static units. In addition, it was decided to relocate and develop the symptomatic breast service back to back with the BreastCheck development at University College Hospital, Galway. In December 2004 the Tánaiste approved additional capital funding of €3 million to support this development.

Capital funding for the facilities at Cork and Galway has been identified under the capital investment framework 2005-09. Funding has also been approved for the relocation and development of the symptomatic breast disease unit at University College Hospital, Galway. This unit will be developed in tandem with the BreastCheck development. The Health Service Executive, in conjunction with the Department, is examining the health capital investment framework with a view to initiating, as quickly as possible, new capital commitments for this and subsequent years.

It is intended to progress the developments at Cork and Galway simultaneously and it is anticipated that the advertisement of the appointment of a design team will be placed in the EU Journal shortly. Given the scale of the investment involved, EU tendering procedures will apply. The design construction and commissioning of projects of this nature generally take approximately two and a half years.

Since February 2000, cumulative revenue funding of approximately €60 million and €12 million capital funding has been allocated to support the programme. Additional revenue funding of €750,000 was provided by the Department in 2005 to further support the national roll-out to counties Wexford, Carlow and Kilkenny.

BreastCheck requires highly skilled specialists working together to ensure best outcomes for patients. A key requirement and dependency for the national roll-out of BreastCheck is the recruitment of a wide range of specialist staff. The largest single requirement in terms of staff numbers is specially trained radiographers who will provide screening services both at the static centres and at mobile clinics.

Until now specialist mammography training for both screening and symptomatic breast services has been undertaken overseas. The Department is supporting the development of a national training centre in mammography to be operated under the auspices of BreastCheck adjacent to its Eccles unit on the campus of the Mater Misericordiae Hospital in Dublin. This facility will greatly enhance our training capacity and enable Ireland's needs to be met here at home. The physical infrastructure for this centre requires an investment of more than €750,000 and BreastCheck is now seeking tenders for this work. The centre will be led by a specialist tutor and will provide training for BreastCheck and symptomatic services. The centre will open at the end of this year and will be in position to support the roll-out of BreastCheck.

Interim proposals regarding a limited screening service through the deployment of some mobile units and the deployment of temporary facilities have been considered by BreastCheck, pending the roll-out of the national breast-screening programme. BreastCheck is primarily a radiological, as opposed to surgical programme, with fewer than eight women per 1,000 requiring surgical interventions. The competence of the radiologist is crucial in the detection of screened cancers.

Radiological quality assurance for breast cancer screening dictates a minimum viable screening throughput of 22,500 mammograms per annum. Based on a 75% uptake this requires an eligible population of 30,000 per annum or 60,000 over two years. The 2002 census shows that the total eligible population in the western region is 57,288 and is 71,888 in the southern region. It would not be possible to quality assure a population-based screening programme for a smaller population than this within quality assurance parameters. BreastCheck has advised the Department that to ensure that a quality assured breast-screening programme is available to all women here, the optimum approach is to work towards the development of the two static clinical units referred to earlier.

The current priority is to progress the roll-out of breast screening to women in the target age group throughout the rest of the country. When the national roll-out of the programme is sufficiently developed and it is assured that quality service is being delivered at national level, consideration will be given to including older women and continuing screening of women in the programme who have reached 65 years of age. More than 60% of women diagnosed with cancer here are under 65 years of age. However, we have no plans to target women below the age of 50 years. This position is consistent with the report, Development of Services for Symptomatic Breast Disease, which states that clear proof of the value of population screening has up to now been confined to women over the age of 50 years. This is also consistent with the recent recommendations adopted by the European Union, advocating the introduction of cancer-screening programmes, which have demonstrated their efficacy having regard to professional expertise and priority setting for health care resources.

The majority of women diagnosed with breast cancer will be diagnosed and treated outside of the BreastCheck programme. It is necessary therefore that we support both the symptomatic breast disease services and the screening services to ensure that comprehensive breast cancer services are available for all women. The report, Development of Services for Symptomatic Breast Disease, which was published in 2000, recommended the development of new organisational structures for the provision of symptomatic breast disease services to improve the quality of care. It made a number of recommendations based on the requirement of good care, which included the establishment of specialist breast units throughout the country. The report recommended that each unit should be based on a population of 250,000 to 300,000 from which it is expected to identify a minimum of 100 new primary breast cancers per annum. The report concluded that this level of workload is necessary to sustain the collective workload of the multi-disciplinary team involving surgeon, radiologist, pathologist, medical oncologist, radiation oncologist and clinical nurse.

Breast cancer is the individual site-specific cancer which has received the most investment in recent years and more than €60 million has been made available for development of these services since 2000. The benefit of this investment is reflected in the significant increase in activity, which has occurred with inpatient breast cancer procedures increasing from 1,386 cases in 1997 to 1,812 in 2003, an increase of more than 30%.

The Government is also committed to the national roll-out of a cervical screening programme in line with international best practice. International evidence demonstrates the proven efficacy of programmes that are effectively managed and meet quality assurance standards. Careful planning and consultation with relevant professional and advocacy stakeholders is required before definite policy decisions are made on a national roll-out. The pilot cervical screening programme commenced in October 2000 and is available to eligible women resident in counties Limerick, Clare and Tipperary North. Under the programme cervical screening is being offered, free of charge, to approximately 74,000 women in the age group 25 to 60, at five-year intervals. Almost 83,000 smears have been processed through the programme.

To December 2003 histology findings relating to pre-cancerous indicators were reported in 747 women screened. Carcinoma was diagnosed in a further five women. The national roll-out of the cervical screening programme is a major undertaking with significant logistical and resource implications. The former Health Board Executive commissioned an international expert in cervical screening to examine the feasibility and implications of a national roll-out of a cervical screening programme. The examination included an evaluation of the pilot programme, quality assurance, laboratory capacity and organisation and the establishment of national governance arrangements. The evaluation of the pilot programme is a key element in informing the development of a high quality cervical screening model for Ireland. The expert's report was published in December 2004. The report reviewed the operation of the pilot programme in the mid-western region and identified improvements that may be needed in the context of a national expansion.

The Department is now consulting the Irish College of General Practitioners, An Bord Altranais, the Academy of Medical Laboratory Science, the Institute of Obstetricians and Gynaecologists of the Royal College of Physicians of Ireland, the faculty of pathology of the Royal College of Physicians of Ireland, the Women's Health Council and the Irish Cancer Society. Consultation with these key stakeholders is well advanced and will be completed in a matter of weeks. The Department has also met representatives of the Well Woman Centres. All the groups consulted so far are fully committed to a national cervical screening programme. Following completion of the consultation process the Department will examine options for the roll-out of a national cervical screening programme.

A key concern for the pilot programme and any future national roll-out was the need to provide a quality service in line with best international standards. In this regard, a national expert advisory group on cervical screening was set up to oversee the implementation and operation of the pilot programme. This group produced quality assurance guidelines for the national cervical screening programme. These guidelines established standards and targets for the main stakeholders involved in the delivery of the screening programme, including GPs or smear-takers, laboratories, colposcopy service and the register office.

Outside of the programme many women present for opportunistic smear tests, the number of which has increased substantially in recent years. Overall, more than 230,000 smear tests were carried out in laboratories throughout the country last year. To meet this increased demand additional cumulative funding of approximately €14.5 million has been provided by the Department since 2002 to enhance laboratory and colposcopy services. This funding has enabled the laboratories to employ additional personnel and purchase new equipment, thereby increasing the volume of activity. These initiatives have resulted in a reduction in waiting times for smear test results.

The programme also supports opportunistic services, particularly in the area of quality assurance and new technology. Additional revenue funding of €1.1 million was allocated to the programme this year to support the introduction of liquid based technology in laboratories where it is not available and support the development of quality assurance and training programmes. The introduction of this technology will result in fewer unsatisfactory slides which require women to come back for repeat smears and will, therefore, substantially improve throughput in the laboratories. It will also enhance the capacity of the laboratories to deal with any expansion of the current cervical screening programme. The transition of the remaining laboratories to new, more effective testing methods are essential preparatory elements in a national roll-out.

With regard to cancer services generally, there has been a cumulative investment of approximately €720 million in the development of appropriate treatment and care services for people with cancer since the implementation of the national cancer strategy commenced in 1997. The key goal of the national cancer strategy 1996 was to achieve a 15% decrease in mortality from cancer in the under 65 year age group in the ten year period from 1994. The Deloitte evaluation of the 1996 national cancer strategy demonstrated that this figure was achieved in 2001, three years ahead of target.

This substantial investment has enabled the funding of 109 additional consultant posts in key areas such as medical oncology, radiology, palliative care, histopathology and haematology. An additional 245 clinical nurse specialists have also been appointed in the cancer services area. This investment includes the sum of €23.5 million, including €11.5 million for radiation oncology services, provided in 2005 to ensure we continue to address increasing demands in cancer services throughout the country.

The Government's policy on radiation oncology is based on the report, The Development of Radiation Oncology Services in Ireland. Considerable investment will be provided for radiation oncology services in the coming years. The central aim is to ensure access by cancer patients throughout the country to high quality radiation oncology in line with best international standards. Significant progress is being made in implementing the report's recommendations.

Immediate developments in Cork and Galway will result in a significant increase in the numbers of patients receiving radiation oncology in the short term. Two additional linear accelerators are being provided at the supra-regional centre at Cork University Hospital at a capital cost of more than €4 million. The first of these linear accelerators has been installed and the second is expected to be commissioned by the autumn. Last year, approval issued for the appointment of 29 staff for this unit and additional ongoing revenue funding of €3 million to cater for this expansion.

Two additional consultant radiation oncologists will be appointed at Cork University Hospital with sessional commitments to the south-eastern and the mid-western health areas. Cork University Hospital is also in the process of recruiting to fill other key posts required for the commissioning of the new linear accelerators.

The supra-regional centre at University College Hospital Galway commenced treatments for radiotherapy recently. Last year, approval issued for the appointment of 102 staff for this unit, together with ongoing revenue funding of €12 million to cater for this expansion. Approval issued for the appointment of an additional consultant medical oncologist and three consultant radiation oncologists, two of whom have significant sessional commitments to the north-western and mid-western areas. Key staffing is in place and the first two consultant radiation oncologists have taken up their posts.

In addition to revenue funding, approximately €95 million in capital funding has been allocated specifically for the development of cancer related initiatives since 1997. This investment includes €60 million for radiation oncology and €11.9 million for the BreastCheck programme.

Data from the National Cancer Registry show that the overall survival rate from cancer increased between 1995 and 1997 and between 1998 and 2000, with the five year survival rate from breast cancer increasing from 73% to 79% over the period. This reflects the level of investment made by the Government in cancer services. The developments I outlined in cancer services generally and in both screening programmes are a clear indication of the considerable progress made in addressing the burden of cancer in our community. I am glad of the opportunity to put on record the substantial developments which have taken place and to outline the extensive preparatory work necessary before a national screening programme can be implemented. The Government is fully committed to the extension of both programmes to all women throughout the country.

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