Ireland is not a good place in which to find you have cancer, but if it happens, here's a tip: try to live close to Dublin or Cork. Inequalities in the health system are not just about money; geography is also important. Cancer specialists in the south-east, for example, say some women are choosing to have mastectomies rather than face long spells away from home for breast-conserving treatment.
Some other patients, such as those with lung and prostate cancer, do not have a choice to begin with. While radiotherapy, available only in Dublin and Cork, should form part of their treatment, demand for the service exceeds supply, so they must get by without it.
The lack of a radiotherapy unit in Waterford, to serve the south-east, is the single biggest health issue in the region. More than half of the 1,000 new cancer patients in the region each year require such treatment, but there is a 10-week waiting list at St Luke's Hospital in Dublin.
When patients are finally admitted, they must choose between 200-mile-odd round journeys each day for treatment lasting a few minutes, or face long spells away from home.
Patients are not the only ones angered by the situation. Dr Ian Fraser, a consultant in radiotherapy and clinical oncology at St Luke's and the Mater Private Hospital in Dublin, says the current approach is "ludicrous" and it frustrates him to see patients "hauling themselves around the country" to get the treatment they need.
"To drag somebody 100 miles away from home at a time when they are in a crisis and make sure they're lonely for up to seven weeks does not strike one as being sensible. Most patients coming to St Luke's are terrified at the prospect of being away from home at a time when they most need the support of their families," he said.
The Minister for Health and Children, Micheβl Martin, refuses to address calls for a radiotherapy unit in the south-east, or any other region, until an expert group set up in May last year to examine the issue on a national basis reports to him.
The group, chaired by another consultant at St Luke's, Prof Donal Hollywood, was asked to make recommendations on the future development of radiotherapy services, including links with such services in the North. It is expected to report to the Minister next month.
Galway, it was decided at the outset, is also to get a radiotherapy unit and this is due to open in 2003.
If the expert group does not recommend that Waterford be given similar status, the issue is likely to dominate the local agenda in next year's general election.
Gordon Watson, a surgeon based at Waterford Regional Hospital and director of cancer services for the south-east, says the region needs two linear accelerator radiotherapy machines, each of which could be used to treat 350 patients per annum.
The financial outlay, he insists, would not be prohibitive. The machines and ancillary equipment would cost £6.5 million, while the cost of establishing an all-inclusive cancer centre with a radiotherapy unit would be less than £12 million.
The absence of such a unit means that some women with breast cancer are choosing to have mastectomies rather than face radiotherapy in Dublin, he says. About one-third of breast cancers can be treated with breast-conserving surgery and follow-up radiation, but for women with young families the prospect of five weeks away from home, or up to 500 hours travelling to receive a few minutes treatment a day, is not a feasible option.
Dr Seamus O'Reilly, the former consultant medical oncologist for the region, also said women had opted for mastectomies for this reason. "I cannot say this particular person or that one did, because the factors involved are complex. But when you see the look on a patient's face when you tell them they must travel to Dublin for therapy, which could be available locally, you know that that is also a factor."
Breast cancer patients are not the only ones losing out. Mr Watson and Dr Fraser both stressed that most cancers nowadays require a "multi-modality" approach, in which chemotherapy, surgery and radiotherapy are integrated. Such a service is simply not possible under current circumstances, which is why prostate and lung cancer patients are not even referred to St Luke's, but instead remain in Waterford where chemotherapy is available.
"People with cancer of the colon or rectum could also benefit from radiotherapy, but we can't afford to wait the length of time it takes to get into St Luke's so we have to proceed with surgery without the radiation treatment," said Gordon Watson.
Despite such apparently persuasive arguments, Dr Fraser admits to being "nervous" about the expert group's findings. The fear in the south-east is that the committee will decide that the region does not have the critical mass, in other words a large enough population, to support a radiotherapy unit.
In its submission to the committee, the Eastern Regional Health Authority did not directly express a view on whether such a unit should be sited in Waterford. Implicitly, however, it suggested the south-east's claims did not measure up.
The submission said a minimum critical population and patient throughput was needed to maintain expertise and specialisation. A study carried out in Britain, the Calman-Hine report of 1995, it pointed out, had recommended that a population of a million was necessary to provide the critical mass of patients for a cancer centre, with "a population of two-thirds of a million being the absolute minimum".
The south-east has a population of 400,000. Its case is further undermined by the ERHA's claim that even if radiotherapy services are developed in Waterford, "it is likely that patients from parts of the south-eastern region, especially those living in Carlow, north Kilkenny and north Wexford, will continue to receive radiotherapy services in Dublin".
"In general, patients from the south-east attend Dublin hospitals for a wide variety of services. Many people for this area commute to Dublin for work," the submission said. It added that the ERHA had no reason to disagree with the Calman-Hine figures.
Dr Fraser does disagree, and vehemently so. Only last week, he said, he had spoken to a leading expert in the UK who had said the population needed to support a radiotherapy unit was 250,000. Britain was providing such units in areas of even lower population in order to minimise the distance people had to travel. "To say the south-east does not have the population is nonsense."
Wherever you live in Ireland, access to radiation treatment is not what it should be. The World Health Organisation says that 50 per cent of cancer patients would benefit from radiotherapy; in the Republic, only about one in five get access to such treatment. "It really does make a difference in terms of life and death", says Dr Fraser.
Europa Donna Ireland, a European organisation which raises awareness about breast cancer, says that a woman diagnosed with breast cancer in Ireland is twice as likely to die from the disease as a woman in the US.
Dr Fraser insists that concentrating the service in a few locations actually makes it more expensive to deliver. It costs £200 a night, he says, to look after a patient in St Luke's who could be receiving treatment close to his or her home.
He believes there should be radiotherapy units, serving the island of Ireland, in Belfast, Dublin, Waterford, Cork, Limerick, Galway and Derry.
"There is no reason why we cannot co-operate and all work as part of the one unit." Settling for less, he claims, will be to settle for a "sub-optimum" level of care.