Marc MacSharry (Fianna Fail)
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My matter concerns the need for the Minister for Health to confirm that patients with breast pain referred by general practitioners in the north west to the national cancer control programme's symptomatic breast clinic in Galway are having their referrals returned to general practitioners without assessment and with instructions for the patient to self monitor with the aid of a booklet and form filling for three months. I ask the Minister to account for the effects this three-month delay will have on the 7% of women whose symptoms are the result of life-limiting conditions such as breast cancer.

The Minister will be aware of a letter I sent him, to which I have had no response as yet and which I also sent to the head of the national cancer control programme, Dr. Susan O'Reilly. The letter relates to a case of a lady in her 40s who presented to her GP with breast pain, mastalgia. The GP referred her to the symptomatic breast clinic in Galway. Some time later she received a letter from her GP stating that a response from the breast clinic on her referral had been received and asking her to come in to discuss it at her earliest convenience. Naturally, she was very concerned and went to her GP. I have a copy of the unsigned letter from the clinic which I have also sent to the Minister. Whether it is unsigned to preserve plausible deniability, I do not know. The letter is headed "Symptomatic Breast Service, University Hospital, Galway" and it states that the numbers of patients attending symptomatic breast clinics nationally has gone up from 22,000 to 39,000, that the numbers being seen are causing difficulties in terms of volumes attending and it further goes on to say that it is felt that certain people might be better dealt with initially in primacy care settings.

One wonders about primary care. She went to her GP, the GP referred her to the clinic and the clinic sent her back because it seems volumes are causing difficulties. She was then presented with a booklet, the cover of which I have with me, on breast pain. The back page of the booklet has a table that one can fill out. The patient is supposed to diligently fill out when she has had pain. There is one small box per day for three months. I do not know how accurate this can be. As the lady said to me, if she had eight instances of pain throughout the day or sporadic pain, how would she record it? On the surface, it seems like a very poor way to reduce numbers attending a clinic. I need not remind the Minister of the mistakes of the past.While we celebrate the statistical improvements and benefits of the national cancer control programme and other clinical programmes like cardiac care, the north west of the country has been left completely on its own. While the population of the region is a little bit smaller than the rest of the country and statistically the country looks good because 80% of the people live elsewhere, the reality is that the closest breast clinic for the region is in Galway because the one that was in Sligo was moved. Now it seems that ladies, when they are referred, are being sent back, and I do not know whether that is due to an administrative exercise or whether it is a trained oncology nurse or an oncology specialist who decides they are fine and that they will not bother seeing the patients with mastalgia given what the GP has told them in referring the patients. I know statistically that 93% of women that present with mastalgia are fine but 7% are not and, sadly, they will go on and have a much more serious illness.

Does the three-month delay impinge in any way on the outcomes for these patients? Does it impinge on the success of treatment that would be available to them? Does the delay threaten their lives? Luckily for this lady to whom I refer, who is a health professional and a very formidable woman, she had the financial means to book a private mammography within a week. However, she was still unhappy and contacted the breast clinic to complain. After she was passed from Billy to Jack, she was told she should never have seen the letter to the GP and that it was not intended for her. She kicked up a fuss and got an appointment in the end. How many people are less formidable? How many people at their most vulnerable, suffering breast pain and who are worried about what it could be - one hopes they are in the 93% rather than the 7% - are diligently filling out forms at home because we cannot cope with the numbers? Is that affecting their health? That is a legitimate question. What is of concern is that there was an unsigned letter to a GP, no response from the Minister's office and no response from Dr. Susan O'Reilly. This whole issue is of concern to me.

Perhaps the Minister might also comment on the following. His colleague, Deputy John Perry, has announced in media in the north west today the return of post-surgery mammography services at Sligo General Hospital. Will the Minister confirm, deny or explain the situation?

Leo Varadkar (Dublin West, Fine Gael)
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I thank Senator MacSharry for raising this issue and giving me the opportunity to update the House on the matter. The symptomatic breast clinic at University Hospital Galway is part of a range of services that are in place for women with breast symptoms. Referrals are dealt with in accordance with the guidelines that have been developed by the national cancer control programme.

Most women experience breast pain at some stage. While this can cause worry, in the absence of other symptoms, breast pain is rarely indicative of breast cancer. The national cancer control programme, in collaboration with the Irish College of General Practitioners, developed a booklet to support women with breast pain. The booklet explains the types of breast pain, their possible causes and how pain might be easily remedied. It contains a three month diary to help determine whether the pain is cyclical or non-cyclical as this information can help with prevention and care. This approach is evidence-based and good standard practice. The booklet highlights the importance of making a specialist referral if other symptoms are present in addition to breast pain.

GPs have also been provided with a guideline for managing breast pain in primary care. The guideline contains the same advice as that in the patient booklet. Where the patient's clinical examination is normal, she is asked to follow the advice in the booklet for three months. If after that time the pain has not resolved, a referral is warranted. All referrals to the symptomatic breast clinics in Dublin, Cork, Waterford, Limerick, Galway and Letterkenny are triaged on receipt and appointments are then offered.

Breast cancer survival in Ireland has improved significantly in recent years due to a combined approach of screening, symptomatic detection and improved treatment. Breast cancer five-year survival is now estimated at 81% for women diagnosed between 2006 and 2011, which represents an increase from 72% for women diagnosed between 1994 and 1999.

Last November, I announced the extension of BreastCheck to the 65-69 age group which is in keeping with EU guidelines. I am pleased to confirm that the first invitations have issued and the screening of 500 women in this age cohort will take place this year.

Earlier this year, I launched the national clinical guidelines on the diagnosis, staging and treatment of patients with breast cancer. Clinical effectiveness is fundamental to the health service. Implementing good quality clinical guidelines and audit will improve health outcomes for patients, reduce variations in practice and improve the quality of clinical decisions. I assure the Senator that all women with breast symptoms are welcome at specialist breast services, including women with persistent and troublesome breast pain as outlined in the guidelines.

Marc MacSharry (Fianna Fail)
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With respect, the Minister has not answered my questions. What about the 7% of women who will have a problem? What about the three-month delay in their being seen? What is the situation in this regard? The Minister also did not answer my question on Deputy Perry's announcement that the people of the north west will have post-surgery mammography services.

Leo Varadkar (Dublin West, Fine Gael)
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I am the Minister for Health but I cannot answer clinical questions. If the Senator has clinical questions on guidelines on appropriate-----

Marc MacSharry (Fianna Fail)
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Surely the Minister can answer as a physician.

Leo Varadkar (Dublin West, Fine Gael)
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No. I am a physician but I am no longer a registered doctor. Therefore, I am not up to date with everything and will not proffer medical advice. Clinical guidelines and referral protocols are drawn up by the national cancer control programme. If the Senator wants to-----

Marc MacSharry (Fianna Fail)
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I have no training at all yet I can see that 7% of the people are at risk.

Paddy Burke (Fine Gael)
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The Minister is here as a Minister and not as a medical doctor.

Leo Varadkar (Dublin West, Fine Gael)
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If the Senator wishes to question the people involved in the programme, he can do so. I know that across the health service we have large numbers of inappropriate referrals to specialist clinics which can give rise excessive volumes. It means that patients who need to be seen quickly are not. Therefore, inappropriate referrals are a risk and we should not be trying to get everyone into a specialist clinic when it is inappropriate for them to be there. The Senator will have read from some media coverage and academic reports that there is a difficulty with young women with breast pain and no other symptoms being referred inappropriately to specialist clinics. That is why referral protocols are put in place to give doctors appropriate guidance on how they should handle patients, how and who they should refer to specialist clinics and when. Those guidelines are not drawn up by politicians but by the national cancer control programme in co-operation with the Irish College of General Practitioners, as is entirely appropriate.

In terms of the other question raised by the Senator, I do not have an up-to-date briefing on the matter. It was not the topic he raised so I cannot give him an update on it today.