The report shows the gaps in our cancer services, so we can initiate action and debate for the future, writes Dr Muiris Houston, Medical Correspondent
The first five-year analysis by the National Cancer Registry of Ireland of cancer trends is most welcome. Five years is a significant milestone in the analysis of cancer statistics, not least because an individual's survival over that period of time has long been the yardstick by which treatment effectiveness has been judged.
Before analysing treatments and outcome, we must acknowledge the sobering statistic that one in four of us will die from cancer. While this statistic is no different from other developed countries, it emphasises the need to make cancer services a priority within our health system.
The report has two important geographical findings. The first is that, compared with other EU states, we have higher rates of cancer of the colon and melanoma (cancer of the skin). Secondly, the incidence of cancer is generally higher in the Eastern Regional Health Authority area, for both genders but particularly for males. In contrast, the population of the Mid Western Health Board and Western Health Board has a lower incidence of cancer.
However, it is the chapter in the report dealing with cancer treatment which poses the most fundamental questions about our cancer services. Why did 50 per cent of patients with lung cancer receive no cancer-specific treatment and why were 57 per cent of those with leukaemia not offered chemotherapy? These are disturbing figures which are made no more palatable by international comparison. The non-treatment rates for lung cancer in the US, for example, are in the 15 to 20 per cent range.
Two-thirds of patients in the Republic with last-stage stomach cancer received no cancer-specific treatment. If they lived in the United States, only a third would have been denied treatment.
There is also a significant age bias evident in the treatment figures, which cannot be explained by the person's gender, where they live or how late in the disease the cancer presented itself. This is worrying and suggests the possibility of an inherent ageism within our health services.
Younger people were twice as likely to receive treatment for melanoma skin cancer as those aged over 65. Was this because older people decided not to have treatment because of concerns about side effects or a perceived lack of benefit?
Was it because physicians did not pursue aggressive treatment because of higher levels of other illnesses which, it could be argued, rendered those patients less able to tolerate cancer therapies or was it because of implied age-based referral and treatment policies within the system?
Whatever the reason, there is a powerful argument for the development of national treatment guidelines for all major cancers which must be age-specific. There is also a need for a public debate on whether there is rationing within the system, as may happen when services are diverted to younger patients because they are expected to live longer and respond better. This poses an ethical as well as a practical dilemma.
Why are some patients receiving no cancer-specific treatment? It could be because they are presenting late, which is undoubtedly a factor in some cancers. Or is it because of a gap in services which is potentially a much more damning explanation?
At least part of the reason is the patchy availability of radiotherapy services in the State, which is borne out by some of the figures in the report. The Republic's two radiotherapy units are based in Dublin and Cork; while 39 per cent of patients nationally have radiotherapy for breast cancer, only 24 per cent of those living in the Western Health Board benefit. A patient who lives in the three western seaboard areas is less likely to received radiotherapy for breast cancer than those in in the eastern half of the country. Such regional variations represents an inequity within the system which must be addressed.
That a large number of cancers are not staged at diagnosis is also a source of concern. Staging is the process by which doctors decide if a cancer is early or late and whether it has spread beyond its original site. It is a key factor in deciding what treatment will work best. Therefore, we need to perform better in comprehensively diagnosing cancers if we are to maximise the appropriate use of treatment.
The National Cancer Registry has done an excellent job since it began issuing cancer data in 1994. With this report, we can clearly see the holes in our cancer services, begin to initiate action and start a valuable debate on where we go from here.