Why do Irish women have a higher mortality rate from breast cancer than women in other Western countries? OECD figures show a 45 per cent mortality rate in the Republic. But with approximately the same breast cancer incidence, Australian women have a mortality rate of only 33 per cent.
Dr John Crown, a medical oncologist at St Vincent's Hospital in Dublin with a special interest in breast cancer, wrote an MBA thesis last year which looked closely at cancer services in the Republic. He was forthright in his opinion as to why this State lags behind other Western nations.
"There is no doubt in my mind that the cancer treatment service which I joined on my return from the US in 1993 was clearly, measurably and palpably among the very worst in the developed world.
"Such services as existed were thinly spread out across a network of small hospitals, none of which was able to provide modern comprehensive cancer care. In 1993 there were a total of five medical oncologists in approved posts, four in Dublin and one in Galway (who was actually appointed as a haematologist). Incredibly, there was no medical oncologist appointed as such outside Dublin in the public service," he wrote.
What are his views on breast cancer services in the Republic now, following the appointment of extra specialists?
"There will be an improvement in breast cancer treatment here as a result of the recent appointment of medical oncologists and other specialists in breast cancer care," he says.
However, he remains worried about major flaws in our cancer care system, specifically the infrastructure, access and funding difficulties which persist.
The National Cancer Strategy, published by the Government in 1996, is in Dr Crown's view a "fundamentally and fatally flawed, ill-conceived, crisis management document, rather than a serious attempt to address the problem". He says that it fails to grasp the opportunity to centralise cancer services along the lines of oncology practice in the US which, he says, is the best country in the world in which to be diagnosed with breast cancer.
That country's 1971 National Cancer Act had at its core the creation of large cancer treatment facilities called Comprehensive Cancer Centres. These units have a full range of diagnostic, treatment and support services for cancer patients. According to an editorial in the Journal of Clinical Oncology, the overall cancer mortality rate is now falling in the US. What changes would Dr Crown make here to emulate the US achievement? He would like to see one comprehensive breast cancer centre in each health board area. Dublin, he says, needs three designated units, one in each area of the Eastern Regional Health Authority, in which radiotherapy, chemotherapy and surgery would be available together in a dedicated multidisciplinary effort to reverse mortality.
Perhaps controversially, he would close St Luke's Hospital where most cancer patients travel for radiotherapy at present.
"We have to stop the ludicrous situation whereby patients are ferried around the city on their way to and from St Luke's. There is no hospital in the public sector with all three forms of treatment available on one campus, not one. It is an incredible situation and, according to the national cancer strategy, this will not be remedied for Dublin."
The last five years have been a "golden age" in terms of drug treatment for breast cancer. These are expensive treatments, however, and Dr Crown is concerned that the Irish health service is in danger of moving to the British NHS model of so-called "post code prescribing" in which the new treatments would only be available according to budgetary constraints. "Fixed annual budgets will not be able to cope," he says.
At present, hospitals are given a budget in January to last them for a year. This is effectively an incentive to ration care by closing wards and reducing patient throughput. Far better, in Dr Crown's opinion, to have a not-for-profit health insurance system which pays for each patient seen and which encourages productivity.
Waiting lists are a crucial issue, also. "We have waiting lists which are unheard of in other Western countries," he says. Patients can wait several weeks to a month to see a surgeon when they find a breast lump. Routine theatre lists are being cancelled, which adds to the worry - and dangers - of a delayed diagnosis. There can be further delays in hospitals as patients wait for chemotherapy, as well as difficulties posed by having to access radiotherapy in St Luke's Hospital, rather than on-site as is the international norm.
So, how should a patient with a suspicious lump be managed in order to improve the disease outcome?
"She should be seen promptly in a specialist breast clinic located in a hospital which has a comprehensive cancer centre. A needle aspirate or biopsy of the lump is performed quickly.
"The patient should know within one or two days whether she has cancer or not. She should be offered a range of surgical options and would meet her radiation and medical oncologist pre- operatively. A full treatment plan is agreed with her, she proceeds to surgery and begins chemotherapy and/or radiotherapy within weeks of the operation," says Dr Crown.
The Minister for Health has recently appointed a four-member Advisory Group for Symptomatic Breast Cancer Services. Its task is to consider the recommendation of the National Cancer Forum Sub Group, which proposed a nationwide network of 13 specialist breast units - down from the 20 possible locations at present. Closing existing facilities has never been an easy political task. But it is clear that there is no other option if the Republic's dismal place at the foot of breast cancer survival tables is to change.