Mary Harney has promised a nationwide screening test for cervical cancer. Elaine Edwards reports
It's well proven that using smear tests to screen women for cervical cancer is instrumental in reducing their risk of the disease and their risk of death from it. So why does Ireland still not have a national screening programme?
In Britain, a programme introduced in 1988 has resulted in an average 7 per cent decline annually in the number of cervical cancer cases, and women diagnosed with the disease in Britain have less chance of dying than a woman diagnosed here.
The Tánaiste and Minister for Health, Mary Harney, said this month she was "fully committed" to the roll-out of a national cervical screening programme "in line with international best practice".
She didn't give a date for that roll-out and it is still tied up in the torturous politics of the health system.
Essentially, the Tánaiste wants the screening to be quality assured and carried out on the basis of "acceptable targets", whereas GPs want to be paid a fee for carrying out each smear, in line with a pilot cervical screening programme in the Mid-Western Health Board region.
GPs are not happy that Harney is tying the programme to ongoing negotiations at the Labour Relations Commission on GPs' contracts.
Dr Martin Daly, chairman of the Irish Medical Organisation's GP committee, says there is no reason an interim national screening programme, along the lines of the mid-west model, shouldn't be commenced.
"The national pilot programme has been run successfully and cervical screening has been delivered by GPs with high quality care, patient satisfaction and HSE satisfaction," Daly says.
"We feel very strongly that the Minister is playing politics with this issue - she's adept at choreographing events to lay the blame on other parties, in this case the IMO and the GPs, and she is attempting to negotiate through the media, which is, in my view, reprehensible."
Daly says everyone recognises the need for targets as a means of identifying those people most at risk and having them tested, but that the method proposed is a "crude instrument".
New medical cards will not make cervical screening available for women, a facility that should be available free to all women irrespective of their income, he says.
"We estimate up to 100 lives per year would be saved and that 300 cases [of cervical cancer] would be identified," he says.
Other medical sources say, however, that it isn't feasible or desirable to roll out an interim programme because it would be expensive, unco-ordinated and would not be capable of audit.
More than 70,000 women are eligible for inclusion in the mid-west scheme, but more than 900,000 other women throughout the State are not in a screening programme.
Irish Cancer Society chief executive John McCormack welcomes the Tánaiste's commitment to the national programme but also urges the need for proper co-ordination before it is fully rolled out.
"One part of the work that has to be put in place is the negotiations with the GPs. The other bits and pieces include the consolidation of the laboratories and we will need to train more cytologists [smear screening technicians].
"We will also need to invest in new equipment that improves the productivity of the cytologists," he says.
"It's important that it is not rolled out until we're ready. It's really important there's no question over the quality of the programme.
"It will take some time, but not an enormous amount of time before it is resolved, but everybody needs to work towards it," McCormack says.
Around 1,000 new cases of "pre-cancer" - abnormal changes in the cells of the cervix or neck of the womb - are diagnosed each year. There are about 200 new cases of cervical cancer and around 70 women die of the disease each year. The cancer can be treated with great success if caught at an early or "pre" stage as it takes up to 15 years to develop. Women must still, however, present voluntarily for smear tests and pay up to €50 to their GP or healthcare clinic.
They then can wait up to three months for the results, depending on how quickly the results are tested and whether there are administrative delays.
The actual screening of smears is carried out by cytologists, who examine the hundreds of thousands of cells in a sample taken from the cervix by a spatula or a small brush to determine whether they are normal or abnormal.
Abnormalities are graded CIN1, CIN2 and CIN3, the first two of which are low level; the third is a high-level abnormality which carries a high risk of becoming cancer over a period of time if left untreated.
The Irish Cancer Society says there is still much confusion among women who are tested and who, having received an abnormal smear diagnosis, believe they have cancer.
Mostly, they don't have cancer and, even if the cell abnormalities are at a high level, they will never go on to develop it because these abnormalities will then be closely monitored by a doctor and treated if necessary.
A link between cervical cancer and HPV, human papillomavirus, is certain, but this area, says one doctor, requires an entire article to itself.
There are dozens of types of HPV, but types 16 and 18 and some others, known as oncogenic types, are present in almost all cervical cancers, according to Prof Walter Prendiville, consultant obstetrician at Tallaght and the Coombe hospitals.
"The reason cervical screening works is because cervical cancer has a huge, long pre-cancerous phase," he says.
"A woman in Ireland who gets cervical cancer has definitely got a higher chance of dying from it than a woman in England who gets it. The reason for that is it presents much later here than it does in the UK because we don't have a screening programme."
Cytology is still an imperfect science and a proportion of abnormalities will be missed.
"It's very subjective and it's quite normal for smears to miss disease. But because the natural history is 15 years and because smear tests in a screening programme are every three or four years, the chance of missing it may be 10 or 20 per cent," says Prendiville.
"If you have a second one it's down to 1 or 2 per cent and the third down to 0.1, so the chance of missing it over 15 years is actually very small," he says.
"As a result of all that, if you implement a national, systematic call and re-call programme, you will profoundly reduce the risk of cervical cancer."