Five years on, what progress have we made?

MEDICAL MATTERS:Assessing Ireland's cancer control strategy

‘IRELAND WILL have a system of cancer control which will reduce our cancer incidence, morbidity and mortality rates relative to other EU-15 countries by 2015. Irish people will know and practise health-promoting and cancer-preventing behaviours and will have increased awareness of and access to early cancer detection and screening. Ireland will have a network of equitably accessible state-of-the-art cancer treatment facilities.”

This is the vision for cancer set out in the National Cancer Forum’s cancer control strategy, published in 2006. Some five years later, how have we done?

The first director of the national cancer control programme (NCCP), Prof Tom Keane, by common consensus, played a blinder. Using breast cancer as his point of attack, he successfully set up a network of eight specialist cancer centres throughout the State. Some significant hurdles had to be overcome, with political casualties in Sligo-Leitrim incurred en route.

An indirect measure of the success of the breast cancer centres is that Keane's successor, Dr Susan O'Reilly, has noted that they are now attracting healthy women who do not need screening. But a study in the current issue of the Irish Medical Journal, carried out by doctors from the Department of Surgery at NUI Galway, shows that GP referrals made using NCCP referral guidelines correlate well with consultant breast surgeons' opinion as to their urgency.

With the spine of centres in place, attention is now being directed at rationalising the care pathways for other cancers. The treatment of lung cancer, the malignancy with the poorest prognosis, is now offered in four of the eight centres, although rapid access assessment clinics are located in all eight. Some 95 per cent of all patients who attend a lung cancer rapid access clinic will be offered an appointment within two weeks of referral, and the hope is to improve the miserable statistic of just 12 per cent of people surviving five years after diagnosis.

Rapid access prostate cancer clinics will be operational in all eight centres within weeks. However, the NCCP is vague about the location of the six centres it says will eventually treat the disease. Given the rapid rise in the number of diagnoses of prostate cancer in the Republic, this reduced figure may seem odd but probably reflects the fact that many prostate cancers are diagnosed at a stage where specialist surgery is not indicated.

Plans to rationalise the treatment of melanoma – the most serious form of skin cancer – are at an earlier stage with the NCCP saying it is “currently developing skin cancer services and is planning towards establishing pigmented skin lesion clinics in hospitals across the country in co-operation with the HSE and new consultant dermatology appointments will be made to facilitate the development of the service. It is anticipated that the number of cancer centres carrying out complex melanoma surgeries will be less than the eight.”

Rectal cancer, usually classified with colon cancer, represents a particular surgical challenge. The aim is to have moved from an original 30 treatment centres to the eight specialist centres by the end of 2011. But probably the biggest surprise is that the centralisation of treatment for colon cancer will not take place. Although the same research evidence supporting improved patient outcomes with greater surgical volumes in breast cancer does not exist for colon cancer, the importance of a standardised multidisciplinary approach to overall disease management remains. To continue to have the Republic’s second commonest cancer managed in units outside the core network will cause some surprise.

So, how do we compare with our European neighbours? The number of people dying from breast cancer in Ireland has fallen since the 1980s, but mortality rates from the disease are still the second highest in Europe. And while we have definitely moved on, it will take the full 10 years of refocused cancer care to see tangible results. Based on comparisons with an EU-27 average, we still have an amount of catching up to do (see graphic).

Whether our cancer incidence, mortality and morbidity will have fallen relative to an EU-15 average by 2016 remains to be seen.

Cancer: The Big Picture

Female Breast Cancer

Prevalence: Leading cause of cancer in women (excluding skin cancer).

Annual cases:About 2,500 women are diagnosed with breast cancer in the Republic.

Breakdown: 75% of patients are over the age of 50.

Cumulative risk: Before age 50 = 1 in 48; Before age 65 = 1 in 16

Projected no. of cases:

2010: 2,720

2030: 5,670

% increase: 108

Lung Cancer

Prevalence: Rates are increasing for women and decreasing for men (due to patterns of smoking)

Annual cases: About 2,000 people diagnosed with lung cancer in the Republic.

Breakdown: Less than 1 per cent of new cases occur before age of 40

Projected no. of cases:

2010: 2,084

2030: 4,086

% increase70

Melanoma Skin Cancer

Prevalence: It is the third most common cancer diagnosed in the 15-44 age group

Annual cases: Over 700 new cases diagnosed in the Republic

Cumulative Risk:Before age 75 = 1 in 78 for men; = 1 in 80 for women

Projected no. of cases:

2010: 762

2030: 1,918

% increase154

Colorectal (Bowel) Cancer

Prevalence: Colorectal cancer is the second most common cancer in both men and women

Annual cases:About 2,400 new cases in the Republic

Cumulative risk: Over two –thirds of people diagnosed are 65 or over.

Projected no. of cases:

2010: 2,422

2030: 4,805

% increase97

Prostate Cancer

Prevalence: Leading cause of cancer in men (excluding skin cancer)

Annual cases:About 2,800 new cases in the Republic

Cumulative Risk: Before age 50 = 1 in 485; Before age 70 = 1 in 13

Projected no. of cases:

2010: 2,871

2030: 5,668

% increase97

Sources: National Cancer Control Programme and National Cancer Registry