BREAST CANCER SCREENING (Hansard, 4 November 1974)

§ Mrs. Joyce Butler (Wood Green)

It is difficult to speak in measured, scientific terms about cancer of the breast, which is still the biggest single killer of women and about which many women are deeply worried for most of their adult lives. Many worry because relatives and friends have died from breast cancer or because there is a history of cancer in the family. Others worry because the breasts are a sensitive area of the body, subject to various changes and discomforts which they cannot interpret.

In the past most of the women kept their worries to themselves, often with tragic results. Many women do so still. With the progress of health education and more stress on preventive medicine, I feel there has been an important breakthrough in the battle against cancer, which is that more and more women are facing the possibility of cancer and seeking medical advice. Bringing cancer out into the open has been half the battle in seeking its cure. In this connection we must all be very much in the debt of Mrs. Betty Ford and Mrs. Rockefeller for the selfless and courageous acceptance of publicity during their private agony, which has encouraged women everywhere to face their own fears.

This is why I have chosen this subject for debate. As the founder of what is now the Women's National Cancer Control Campaign I have seen some of the letters which have been coming into the campaign recently. These letters included a particularly poignant one from a father concerned about the prevention of cancer in his 18-year-old daughter, whose mother died from breast cancer soon after her daughter was born.

849 It is a fact that women have been going in increasing numbers to clinics and to their general practitioners seeking to secure cancer screening in recent weeks. Many have been bitterly disapponted because, while the success of the campaign for screening for cervical cancer has produced 573 cytology clinics in England, I understand that only about 66 counties and boroughs arrange for breast examination. This is despite the fact that cancer of the breast is four times as common as cervical cancer.

Even more disquieting is the evidence accumulating from personal reports that many general practitioners are somewhat off-putting, to put it mildly, when asked by women about possible breast cancer symptoms. Since it is necessary for a general practitioner to refer a woman to an early diagnostic clinic, this is a serious weakness in any early detection service.

While much that needs to be done in this area is expensive, one simple improvement which could be made in the service, which would cost very little, would be for the Department of Health and Social Security immediately to ensure that a circular is sent to all general practitioners alerting them to the urgency of early detection of breast cancer. Most important, it would set out for them the diagnostic facilities in their areas. Many doctors seem unaware of the facilities which are available within their areas.

It has been estimated that we need about 30 of the early diagnostic clinics throughout the country. That compares with the half-dozen or so that we actually have. The additional clinics are necessary because of the vital importance of making early diagnosis available to women in the high risk groups, whether or not they have symptoms. I refer here to women preferably over 45 but certainly over 50 and to women with a family background of breast cancer.

I appreciate that there is hesitation about trying to establish comprehensive screening services for breast cancer because of doubt about the viability of such mass breast screening. However, I have found the unanimous view among everyone working in this subject that every possible facility should be made available to the high risk groups and that 850 this is the most intelligent use which could be made of the resources available.

Since I feel so strongly about this matter, I wonder whether my hon. Friend the Minister will consider whether the time has come to launch a campaign urging every woman on reaching the age of 50 to have a clinical examination for cancer of the breast as a matter of course. We may have no idea of the numbers involved, because as far as I know no study of the subject has been made. Inevitably some women would not take advantage of the scheme. The numbers might not be very large, and if that were so the cost would not be prohibitive.

It is worth remembering that in the United States 52,000 women die every year from breast cancer. That is the number of lives that were lost in the Vietnam war, yet the toll from breast cancer is at that level every year. Since the proportion of deaths in Britain is the same as in the United States, surely we have a special duty to do something more effective.

I understand that in Britain 11,186 women died from breast cancer in 1971. In 1972 the figure had increased by about 100, and the indications are that in 1973 it will show a further increase of 100 or so.

The situation, therefore, is not improving. I understand, too, that clinics like the Royal Marsden Clinic will soon no longer be able to take in women in the high risk groups who do not have actual symptoms. I hope that my hon. Friend will therefore have something helpful to say about ironing out the deficiencies in the provision for these high risk groups and meeting the increased demand.

I hope that my hon. Friend will feel able to use this opportunity to make a statement about the whole problem of breast cancer screening and say what is being done and what more can be done. I assure him that those who are concerned for themselves and their families are anxious to have the fullest possible information.

Will he say something about the progress of his special research projects in that respect? Will he also indicate what he feels about the value of thermo-mammography since, as I understand it, the BUPA medical centre has found that 851 90 per cent. of the cancers that is discovers have earlier shown up as abnormalities on the thermo-mammography test? Is there any hope that such agreement will be more readily available in National Health Service clinics?

Since there is a great demand for leaflets and booklets on self-examination issued by the Women's National Cancer Control Campaign and by BUPA, has my hon. Friend anything to say about the value of self-examination and is there any possibility that his own Department might issue leaflets or help in the financing of the issue of such leaflets by other bodies?

I ask my hon. Friend to give breast cancer a new priority, by more public information—because everyone, I believe, would welcome the knowledge that the Department of Health itself was taking as much interest in the problem as do all the people working in this field—by giving more information to general practitioners so that they can be more cooperative, by providing more early diagnostic clinics with more effective equipment and by mounting a special campaign directed to the high risk groups.

I believe that I am speaking for all the women in this country when I ask my hon. Friend to consider these points very seriously, because we need a breakthrough in the early detection of breast cancer as a means towards its prevention, and I believe that the time for that is now.

§ The Minister of State, Department of Health and Social Security (Dr. David Owen)

I am sure that the country generally will be grateful to my hon. Friend the Member for Wood Green (Mrs. Butler) for raising this subject. She is the founder of the Women's National Cancer Control Campaign and has taken a great deal of interest in the subject for many years.

First, let me give the bare statistics. Deaths from breast cancer in 1971 were 11,182; in 1972, 11,149; and in 1973, 11,428. Breast cancer is the cause of 4 per cent. of all female deaths and 20 per cent. of all female cancer deaths. To compare that with other important causes of female deaths in percentage terms, coronary disease accounts for about 22 per cent., strokes 17 per cent. and respir- 852 atory diseases 13 per cent. Thus, breast cancer is a major cause of death, and also, of course, a much greater cause of morbidity.

In 1972 in England and Wales there were 31,300 hospital admissions for breast cancer, and 1,400 hospital beds were occupied at any one time by women with breast cancer. New cases represent an incidence of 0.7 per 1,000 females per year, and the mortality rate has risen by 8 per cent. since 1968.

Those statistics are difficult to interpret, and I caution against interpreting swings from one year to another, but there is no doubt that we are dealing here with a considerable problem and it is right that we should be discussing the possibilities of preventive medicine.

For many years I have taken an interest in trying to give greater priority, greater publicity and greater attention to preventive medicine, and I hope that in the New Year the Government will be able to produce a document for the House covering a lot of aspects of preventive health, probably for discussion in the first instance but to bring together all the available evidence.

It is important to point out that clinical examination of women for breast cancer is widely available, and any woman who has the slightest suspicion of symptoms should consult her doctor without delay. Additionally, in recent years a considerable amount of research has been undertaken in the use of several diagnostic techniques, including X-ray mammography, using both conventional film and xerography, thermography, ultrosonography, cytology and various biochemical and immunological tests. This work is still continuing. I must tell my hon. Friend that it is not yet possible to reach final conclusions on the benefits and the drawbacks of each of these methods, but I assure her that we are pushing ahead.

In past discussions there has been a tendency to concentrate on the possible development of a screening service based on the use of diagnostic equipment rather than clinical examination. Although we are not in a position to know which method is the most effective, we consider the development of such diagnostic techniques important. There are a number of problems that need to be resolved before the desirability of implementing the screening service can be determined. The 853 techniques under investigation are known to have appreciable false positive and false negative result rates, these being particularly high for thermography, and even combinations of these tests are not free from error. This might well mean that unnecessary anxiety might be caused to many women, some of whom would have to submit to what might turn out to be unnecessary biopsy procedures. On the other hand, others might be told that they were free from cancer when in fact they were not, and that might result in their delaying a consultation with a doctor when they developed symptoms.

Repeated X-ray mammography results in a significant dose of radiation to the breast. The practical importance of this has yet to be determined accurately, but there is at least a theoretical possibility that more cancers might be induced by regular mammography than would be detected by it. This goes to the point that my hon. Friend has raised. She asked whether we could concentrate on the high risk ages, and she mentioned the age of 50. This is a factor that needs to be considered carefully. Mammography undoubtedly has a place in diagnosing symptomatic breast lesions. If it were used for this purpose, only a small number of women would be exposed on a small number of occasions and the radiation risks would be less than those from other radiological procedures in everyday use. This kind of diagnosis to deal with such suspicions would certainly be helpful, but there are many resource problems that have to be carefully considered.

As my hon. Friend knows, a joint working group was set up in 1971 comprising experts from the hospitals, the medical schools, the universities and the research institutes as well as officials of the Health Departments to study all these problems. Working groups have considered a number of projects financed by the Health Departments and these projects are now in progress using different methods and approaches to screening in order to provide the answers that we need. These working parties are in fact producing reports and I would hope that by the end of this year, or perhaps early next year, we shall be able to consider the advice of the Medical Research Council, and then we can consider what, if anything, we should do.

854 As my hon. Friend has asked for them, I give some details of some of the projects. At Ealing there have been 1,074 attendances at the clinic up to July 1974 representing 800 women. At Manchester there is another research project. There is a research project planned for Edinburgh, although there have been some delays with building plans. However, construction work there is expected to commence soon and completion is foreseen for the spring of 1975. In Bath there is a project that will be carrying out clinical examinations and mammography using a mobile screening unit, and there is a survey in South London financed by the Imperial Cancer Research Fund. Here, too, there have been some difficulties about finding a site for the clinic which have not yet been totally resolved. However, the working party will, I hope, be producing a report, the proposals will come to us and we shall then have to decide. For instance, one of the papers which the working party has studied has been on the cost-effectiveness of mass screening. This is expensive.

I know that my hon. Friend is aware of the trials that have been done in New York. The Health Insurance Plan of New York study has shown a statistically significant reduction of about one-third in the mortality of the screened group, though this was confined to those aged 50 to 59 years. This study has been in progress for about seven years and since its inception there have been 70 deaths from breast cancer in the study group compared with 108 in the control group. We can gain some knowledge from experience in New York, but we hope that the trials we are currently mounting will give us a great deal more of the information we need.

Cost-effectiveness is an important question in considering priorities: where does one put one's money? I believe that the approach adopted by the Department under successive Governments is right. This is an area where we are bound to be guided by the professional advice that is available to us. The House has a right to demand, in the interests of the health of the nation generally and of women in particular, that the working party has not been set up merely in the hope that the problem will go away. I assure my hon. Friend that that is not so. I have seen the papers which have 855 been presented to the working party. I have also seen the active interest its members have taken in stimulating specific research projects. All this has been with the objective of providing us with the answer to the question "Is it a cost-effective solution?"—and perhaps also the answer to the question "Is it the right use of resources at this time that in an attempt to cure, eradicate or reduce cancer we should put money into screening?" I do not think the case is yet proved, and it is not fair to make a judgment until we have the conclusions.

I hope that either at the end of this year or early next year we shall be in a position to make an informed judgment. The options open to us would be to put more resources into more research projects, to try a screening programme in certain areas or to concentrate on an age group, which was one of the suggestions made by my hon. Friend.

My hon. Friend made a further useful suggestions about putting out a circular with the aim of making general practitioners more aware of the facilities which already exist and the techniques which are available. I shall give serious consideration to that suggestion. My initial reaction is that, since I shall fairly soon be in possession of expert advice from the working party, it would be premature to take such action, but that it would be appropriate to do this when the 856 working party's conclusions have reached us. I shall give serious thought to producing a circular to all doctors on this subject when we are in a position to give more definite advice some time next year.

With those comments, I hope my hon. Friend will feel that something is being done about this matter. I welcome pressure on us, though I do not think we need it. I am determined to give the highest priority to preventive health —a higher priority than perhaps has been given to it for a number of years.

Breast cancer is an area in which, if we are able to discover adequate diagnostic techniques and apply them successfully, we might well be able to pick up early cancer and then, by treatment, eradicate it. Early diagnosis is therefore of crucial importance. I hope that we shall be able to take some steps towards that end in the fairly near future. At present, however, diagnostic techniques are expensive, and if we embarked on a project on a major scale it would involve a fairly substantial investment without any certainty that the benefits would repay the outlay. But I promise to keep my hon. Friend informed and let her know the results of our conclusions when we have the findings from the working party.