A regional/supraregional model seems the best system for cancer care, writes Dr Muiris Houston
Cancer causes a quarter of all deaths in the Republic. Some 20,000 people are diagnosed with cancer each year; 7,500 patients die of the disease annually.
Along with heart and lung disease, it is the major cause of morbidity and mortality. Getting cancer care right is crucial to a properly functioning health service.
The last National Cancer Strategy was published in 1996. According to an evaluation by Deloitte management consultants, the 1996 document achieved a significant reduction in deaths from cancer as well as securing enhanced spending on cancer services.
However, it did criticise the organisation of cancer care. It found there was a lack of clarity as to the scope and complexity of acute services, and questioned whether geographical considerations were being allowed to compromise the type of care suggested by international good practice.
The National Cancer Forum is even more forthright. "The current arrangements for the delivery of cancer services are not generally in accordance with best practice," it states, adding that there is "insufficient case volume to support the number of consultants and hospitals engaged in oncology surgery".
"The current arrangements cannot be recommended to deliver best quality cancer care."
It is clear, therefore, that the forthcoming National Cancer Strategy will recommend the kind of changes already suggested by the Hollywood report on radiotherapy services.
In other words, fewer hospitals treating larger volumes of patients to achieve better outcomes.
In fact, the report notes that two-thirds of surgeons providing breast cancer services carry out less than 10 procedures per year at present.
It also quotes a rather stark observation from Comhairle na nOspidéal where the statutory body for hospital consultants says it "accepts that there is a significant number of consultants doing small numbers of certain procedures, and this may lead to worse patient outcomes".
So what is to be done to rectify the situation?
The National Cancer Forum calls for specialist cancer centres seeing a minimum population, which are networked to other parts of the health system.
Crucially, it says: "The size of the population that they serve should ensure that there is a balance between geographical access and the need to ensure that caseload and other economies are maximised."
In other words, it is pushing for a regional/supraregional model for cancer services.
While not naming hospitals or cities, the document says the designation of regional and supraregional "will reflect existing designations in the area of radiotherapy and breast screening".
What this tells us is that final recommendations on the new National Cancer Strategy will almost certainly mirror those already outlined by Hollywood and others. And while they did not bite the political bullet on exact locations either, it is safe to say that the State's smaller hospitals, such as Nenagh, Ennis, Roscommon and Monaghan, will not be carrying out cancer surgery if the new strategy is implemented.
The common cancers such as breast, colon, lung and prostate will still be treated in the regions.
However, the treatment of tumours such as bone, brain and paediatrics cancers will be carried out in single national centres only.
The issue of technology and how it will inform the breakdown of cancer services is also dealt with in the document.
The new Health Information and Quality Authority (HIQA) will be asked to access the capacity of individual technologies, with this assessment deciding the distribution of diagnostic and treatment facilities throughout the State.
There is a welcome acknowledgement of the need to strengthen the team approach to cancer care.
The National Cancer Forum acknowledges the progress made in this regard for breast cancer, but says it needs greater development based on evidence that patients are more likely to survive if they are treated by specialist teams.
The role of primary care is promoted, along with the interesting concept of primary care key workers in cancer care.
This is a clear acknowledgement of how patients sometimes lose their way in our current poorly-integrated health system.
A chapter on governance summarises progress on the implementation of the National Health Strategy. It cites the new cancer strategy as "the first major policy document to be completed in parallel with the reform process", and suggests that its recommendations are pitched to the Health Services Executive.
There are some interesting observations on screening programmes for cancer. While acknowledging the success of Breast Check, the national breast cancer screening programme, it is less certain about the need for a colon cancer programme.
"Emerging international evidence on population screening for colorectal cancer should be kept under review," the document states.
On prostate cancer, it calls for a policy in relation to the use of prostate-specific antigen testing (a blood test for prostate cancer) on an opportunistic basis. There is no such hesitation for cervical cancer when it calls for the national roll-out of a screening programme.
And the document acknowledges the inequalities inherent in population screening when it calls for programmes to ensure full access for lower socio-economic groups.
The current National Cancer Forum document may not fully reflect the detail of the final cancer strategy. What is clear, however, is the commitment to continue the direction set out in the Hollywood report on radiotherapy services.
Given that we are still unsure of the locations of the Dublin north and Dublin south radiotherapy units, months after that report's publication, it is premature to speculate on the exact location of regional and supraregional cancer services. Their location may be clearer when we see the final National Cancer Strategy document this year.