Madam, - The main reasons for Ireland's current poor survival rates for breast cancer patients are late diagnosis - which is largely caused by deficits in screening - and inadequate and delayed access to treatments such as radiotherapy and chemotherapy. This has been due to a failure to invest in diagnostic and treatment facilities and to a shortage in specialists in oncology and radiation medicine. It is only in the past decade that these shortfalls are being addressed.
The organisation of cancer services and the application of evidence-based guidelines are also deficient. These important quality benchmarks need to be put in context and perspective. Triple assessment and multidisciplinary care are key elements of the new organisational model for breast cancer care. Although a relatively recent development in Ireland, they are now in place in most breast units. But there is little evidence yet to confirm that this team-based care produces better survival rates. Cancer services in the UK are much better organised and concentrated than here. Yet their survival rates for breast cancer patients are only marginally better than ours and lag far behind rates achieved in north and central European countries.
The constant catch-all refrain of "closing small units because they are unsafe or deliver inferior care" does a great disservice to patients and healthcare professionals. The supporting evidence for this contention is very weak for general medical and surgical conditions. Concentrating cancer care delivery on fewer sites is, however, reasonable and acceptable once a comprehensive audit system is in place and each centre is measured by external review as advocated by Prof O'Higgins and reported in The Irish Timesof March 7th.
It may be the first step, but centralising breast cancer services in the eight designated sites is no guarantee that breast cancer survival rates will improve. Furthermore, many senior professionals believe the site selection process was flawed and this fact does not inspire confidence in a collective strategic endeavour whose ultimate aim is to achieve excellence.
The arbitrary new criteria used to choose these sites did not demand any prior quality assurance assessment. Nor was their consultation with many of the specialists providing the current service. Likewise, family doctors, nurses and communities were not party to these decisions. The important criteria of ease and equity of access to these units for patients did not appear to merit any serious consideration. The criteria used self-selected the centres and by design excluded all the peripheral units, particularly those identified in the O'Higgins report of 2000 as being capable of providing quality breast cancer care. It is worth noting that one of the new benchmarks of treating 150 new breast cancers a year has not been reached in some of these designated centres and that a peripheral unit in Drogheda is treating as many new cancers as some of the above.
Drogheda's development into a cohesive, functional, well-resourced regional unit, advocated by O'Higgins in 2000 and assembled over the past five years, is now to be dismantled. The HSE has indicated on its website in recent days its transfer within months to what is currently a less well-endowed and resourced unit in Dublin. Nobody in the unit has yet been formally notified of this. The agendas that drive this kind of implementation process can only seriously undermine the cancer strategy and healthcare reform in general and will erode the confidence of patients in the vocational commitment of doctors and nurses to their care.
Madam, this letter is sent to you in a personal capacity and does not seek to represent the views of my colleagues in the breast unit or the hospital.
- Yours, etc,
F. LENNON, FRCSI, Consultant Breast Surgeon, Dóchas Centre, Our Lady of Lourdes Hospital, Drogheda.