What do the election manifestos say about cancer care? Dr Muiris Houston, Medical Correspondent, believes the parties have difficult choices to make
In many ways the debate about breast cancer services is a microcosm of the debate which urgently needs to take place about cancer services generally.
It is accepted best medical practice to operate a hub-and-spoke model for cancer services. In other words, there is a need for specialist cancer centres throughout the State, each of which will have patients coming from hospitals within its region.
In this way, a critical mass of treatments can take place in each specialist centre which will ensure a better outcome for patients. The surgeons are more experienced because they are doing more operations; the radiologists have better equipment, see more patients and they build up expertise; and patients in these units can participate in clinical trials of the latest treatment combinations rather than having to accept treatment which might already be out of date.
Prof Niall O'Higgins, and his sub-committee of the National Cancer Forum, have demonstrated how such a system might work for patients with breast cancer. In a report published in March 2000 he recommended that the 20 hospitals which currently provide breast cancer services be reduced to 13. Each of these specialist breast units would consist of a multidisciplinary team of surgeons, radiologists, pathologists, oncologists and breast care nurses. They should be based on a population of 250,000 to 300,000 people from which it is expected there would be a minimum of 100 new breast cancers every year.
Why 100 cases? The O'Higgins report presents strong evidence that this is the critical mass at which all members of the multidisciplinary team can function in a cost effective way. More importantly, the specialists need this minimum level workload to maintain their expertise and so save more lives.
There is clear international medical evidence that patients of high-volume units are 15 to 20 per cent more likely to be alive five years after surgery for breast cancer. In addition, these patients are much more likely to be offered additional treatment in the form of chemotherapy and radiotherapy.
Not surprisingly, there has been some opposition at local level at the prospect of losing a pre-existing service. And one of the many complaints by local people and politicians is the distance patients will have to travel under the new arrangements.
O'Higgins acknowledges this in the report, which shows that only 60 per cent of women in the State can get to a treatment centre within one hour. However, it makes specific recommendations to overcome this including improved transport facilities.
O'Higgins suggests that an organised transport service should be part of each breast unit structure, using a bus service, subsidised taxi service or voluntary transport arrangements using support groups.
Despite such overwhelming scientific evidence for its potential success, two years after its publication the O'Higgins report has yet to be implemented. There has been some fudging of regional arrangements, which effectively dilute its recommendations. But essentially no politician has been prepared to bite the bullet of reform.
What do the election manifestos say about cancer care? According to the PDs, regional cancer care centres will be established so the patients do not have to travel 100 miles for ongoing treatment. Fianna Fáil rely on the Health Strategy, which promises that cancer services at local, regional and national levels will be agreed by the end of 2003. The Labour Party gives a clear commitment: "We support the development of regional cancer care centres, starting in Waterford." Fine Gael opts for a prevention approach involving primary care but promises that no patient will wait more than six weeks for diagnosis or treatment "in core specialities".
But the question remains: will politicians ever make the difficult local choices needed to implement a commitment to regional cancer care?