MEDICAL MATTERS Niall O'HigginsUnremitting effort over many decades involving collaboration between hospital doctors and laboratory-based scientists is finally being rewarded. Survival for breast cancer patients and long-term cures are increasing.
For an ever-rising percentage of patients treated for breast cancer, life expectancy approaches that of the normal population. Diagnostic improvements mean more than 90 per cent of breast conditions can be diagnosed with certainty without an open surgical operation.
Improved surgical techniques, minimising the extent of surgery to the breast and reducing the incidence of post-operative symptoms without compromising the long-term cure rate, are now available.
New biological markers, identifiable in cancerous growths, can now provide powerful information as to the likely clinical behaviour of the disease.
Treatments based on these biological measurements are evolving and the possibility of targeted therapy individualised according to the specific biological profile of each tumour is a realistic expectation.
These improvements have not occurred by chance. High standards of care at every level are needed. Specific training and expertise in many medical disciplines - radiology, pathology, biological medicine, surgery, chemotherapy, radiotherapy, plastic surgery, psychology, genetic counselling, palliative care medicine and specialist nursing - is required.
Of great importance is that the input of these specialists should be obtained together at weekly multidisciplinary meetings where decisions involving the care of each woman with breast cancer are made.
The advantage of such multidisciplinary dialogue is immense. Treatment plans and options are discussed twice - at the time of diagnosis and again after the primary treatment. It should no longer be acceptable to have specialist input as a series of sequential opinions without routine inter-specialist consultation conferences.
After these meetings, the specialist surgeon, together with the specialist nurse, discusses options with each patient so that her choice of treatment is a shared and informed one.
Abundant evidence exists that results are better for patients treated in large centres where all the specialists work together. This integrated teamwork is essential for improved survival.
What might have been considered adequate care a decade ago is no longer acceptable, because the evidence now indicates a 25-30 per cent survival improvement for women treated in centres treating large numbers. This improvement is not associated with an individual doctor or specialist, but with the system of care.
However, is not possible to have such systems of excellence in every hospital. It is essential that breast cancer treatment be provided in a small number of highly specialised centres and that these hospitals have all the staff and facilities required.
There is highly convincing data which confirms much better survival rates in specialist centres. It is literally a matter of life and death. Irish statistics indicate significant regional differences in breast cancer survival rates.
These data cannot be ignored. With a general election due within 18 months, one would hope that this issue would be discussed in the context of each woman's right to live and not of local politics.
We know that a woman's chance of survival is best in a specialist centre. Sadly, but essentially, this may require travel and absence from home.
There is also evidence that patients are prepared to travel to specialised units provided that, by so doing, they will receive, not only integrated multidisciplinary care but will also have a survival advantage of up to 30 per cent.
Inpatient stay for breast cancer surgery is often very short, often less than 24 hours. Radiotherapy is often required after operation. Research is now being carried out, testing the value and safety of radiotherapy given as a single treatment during the operation. If this way of delivering treatment proves to be effective, it could be of huge benefit.
Meanwhile, improved systems of transport and accommodation must be provided for patients who need radiation treatment.
Some units here can provide breast cancer treatment which is as good as anywhere in the world.
Indeed, some of the medical specialists concerned have contributed significantly to developing and defining the current international standards of high-quality care.
There remains a sense of frustration that no unit has received the extent of central support which was set out explicitly in the document Development of Services for Symptomatic Breast Disease, approved by the Government last year.
It is encouraging that Health Minister Mary Harney has established a National Quality Assurance Group for Symptomatic Breast Services. This group is expected shortly to outline a list of clinical and administrative performance measures which will be expected of each designated specialist unit.
Such measures will then allow the extent and the quality of activity of each unit to be analysed and compared with other units in the country and with units elsewhere in Europe.
Since around 650 women in Ireland die each year from breast cancer, no one can be complacent. We can do better than this.
Prof Niall O'Higgins is Professor of Surgery, University College Dublin, President, Royal College of Surgeons in Ireland. He is also chairman of the National Quality Assurance Group for Symptomatic Breast Disease Services.