Breast Cancer Screening (Bolton) (Hansard, 17 February 1987)

§ Mr. Tom Sackville (Bolton, West)

I am grateful for the opportunity to raise the subject of breast cancer, the cancer to which women are most vulnerable. It leads to 15,000 deaths a year and many lives—perhaps up to a third of those in the 50 to 70 age range—could be saved if an effective screening programme were provided and if those women who are most at risk could be persuaded to take advantage of it.

The interim report of the Forrest committee has confirmed that there is an urgent need for a screening programme and that mammography is the technique most likely to succeed. The final report of the Forrest committee and the Government's response are anxiously awaited. What I hope to hear is that the Government are able to provide funding for a number of health districts to run their own pilot schemes, but I also expect that Forrest's call for caution will be reflected. To attempt to run full tilt into schemes all over the country in health authorities which are not adequately prepared would lead to serious problems, of which cost would be only one.

Mammography is a sophisticated and specialised treatment. As Forrest says, it would not be sensible to introduce mammographic screening on a United Kingdom basis without providing the necessary back-up services to assess the abnormalities that would be detected.

My principal purpose tonight is to show why Bolton can provide the necessary back-up services and does fulfil the other criteria to run one of the pilot schemes. I believe this for the following reasons.

First, we have the expertise in Bolton to run a scheme. We have radiographers who are used to mammographic techniques, radiologists who are experienced in the interpretation of mammograms, surgeons and radiotherapists who are experienced in the management of breast disease, and pathologists who are experienced in the interpretation of needle biopsies and the localisation of minute breast tumours. For an authority which is not a centre of excellence or a teaching district, to have such a wealth of experience is rare.

Secondly, Bolton has access to substantial charitable funds, partly the balance of a highly successful charitable appeal started in 1985, mainly through the energies of my constituent Mrs. Lena Pickford — the Bolton breast scanner appeal — which resulted in the purchase of a breast scanner for the Bolton royal infirmary. I was persuaded by Mrs. Pickford to jump out of an aeroplane 2,000 ft above Blackpool airport to raise money for the appeal.

I am told that there are sufficient funds to equip a unit with most of the essential hardware. Space has been identified and only a limited amount of capital expenditure would be needed. I am also assured that many Bolton people and organisations have shown a willingness to contribute substantially to a charitable trust to offset part of the running costs of the service.

Thirdly, one of the spin-offs of the appeal and the massive publicity in the Bolton Evening News surrounding it is that women in Bolton are extremely aware of the problem of breast cancer and the need for vigilance. This is reflected in the increased attendance at the local breast 889 clinic. It is widely recognised that no screening programme is likely to succeed unless it achieves a 75 per cent. attandance. Otherwise it is unlikely to make a significant dent in the problem. It would be a pity to allow this heightened awareness to dissipate. Now is the optimum time to introduce a scheme in Bolton.

Fourthly, I emphasise that the introduction of a mammographic screening scheme in what might be called an ordinary district such as Bolton would be a most practical and cost-effective way of testing the Forrest report's recommendations and the practicability of its proposals before their wider application. If only centres of excellence are used, little will be learnt in a management sense and many of the problems that have occurred in trying to introduce a workable national cervical cancer call and recall scheme will be experienced yet again.

The chairman and members of Bolton health authority are highly motivated and involved. Under our general manager, Victor Peel, who is surely one of the most professional and forward-thinking managers in the NHS, the authority has gained a solid track record in encouraging, managing and monitoring new policies and clinical innovations. For example, Bolton runs one of the largest and most successful resettlement schemes for the mentally handicapped. Bolton has started to make sharp reductions in hospital waiting lists by using facilities in outside authorities and in the private sector. Bolton is a training district for new general managers and is one of the three training centres in England specialising in training staff to deal with AIDS.

In 1985, 78 women in Bolton died of breast cancer. There are more than 13,000 women between the ages of 50 and 60 in Bolton, the age group which would benefit most from the screening programme. Through the success of the appeal and in other ways, people in Bolton have shown that they are willing to do their bit to fight this dreadful disease. I appeal to the Minister to ensure that the Government recognise this achievement and designate Bolton as one of the pilot areas for a mammographic screening scheme.

§ The Parliamentary Under-Secretary of State for Health and Social Security (Mrs. Edwina Currie)

I begin by congratulating my hon. Friend the Member for Bolton, West (Mr. Sackville) on his success in the ballot and on raising this most important subject on behalf of his constituents. He is a determined and doughty fighter for his constituents in Bolton and he has shown a great interest in all health care matters. Correspondence on similar topics has also been received from my hon. Friend the Member for Bolton, North-East (Mr. Thurnham). I am sure that my hon. Friend the Member for Bolton, West will be happy if I acknowledge that fact.

The statistics on breast cancer that were produced by my hon. Friend are accurate. There are 15,000 deaths a year from breast cancer, and 24,000 new cases each year. It is the major premature killer of women in middle age. We think that lung cancer will soon catch up, but at the moment breast cancer is the major killer. However, my hon. Friend might not know that about 100 men die each year from breast cancer, so it is also an important issue for men.

890 Mass screening has not been introduced in the past because of serious scientific doubts about the effectiveness of the various methods. In 1979, therefore, the Government started to fund a long-term research programme that is still under way. The objectives of the United Kingdom trials have been to test the effectiveness of different methods, which have been funded to the tune of some £5 million in total—around £750,000 a year—and 250,000 women, aged betwen 45 and 64, are being looked after in eight centres round the country. I had the privilege recently of visiting one of those centres in Surrey. We are expecting a comprehensive report on those trials in 1988.

In 1985, a Swedish study was published that removed many of the doubts about the value of screening by one particular method—mammography, to which my hon. Friend referred. As a result, the then Minister for Health, my right hon. and learned Friend the Member for Rushcliffe (Mr. Clarke), on behalf of other United Kingdom Health Ministers, set up in July 1985 an expert working group under the chairmanship of Sir Patrick Forrest, the Regius professor of surgery at Edinburgh university.

The remit of the Forrest group was, first, to review the available evidence and to consider the extent to which that evidence suggested that there should be a change in United Kingdom policy and, secondly, to set out the policy options, their costs and benefits and overall implications for the Health Service. They were briefed to do more than just look at the screening system. They were briefed to look at all the implications of introducing such a system and what this might mean in terms of treatment and other resources.

The interim report of the Forrest group was received in January 1986 and copies are in the Library of the House. The conclusions of the interim report were: There is a convincing case, on clinical grounds, for a change in United Kingdom policy on the provision of mammographic facilities and the screening of symptomless women aged 50 and over. The report made it quite clear that it would not he sensible to introduce mammographic screening on a United Kingdom basis without providing the necessary back-up services. I think that answers my hon. Friend's point.

The final report, which sets out policy options, their costs and benefits and the implications for the Health Service, was presented to Ministers in November 1986. We are giving it the most careful study and we hope to respond shortly.

The trials that are under way have already produced a considerable amount of worthwhile information. The response rates to invitations to mammographic screening have been between 60 and 70 per cent.—Guildford 69 per cent and Edinburgh 64 per cent. The registers that are in use, which are based on the family practitioner committees' population registers, can never be completely up to date, so it is possible that the true response rates are higher. However, I picked up with interest an element in a letter from the district general manager of Bolton, Mr. Peel, in which he carefully said, and I think he is absolutely right: In starting such a screening programme it is important to recognise from the onset that at least 75 per cent. attendance rate must be obtained to show any significant improvement in the population. In view of the exceptionally successful Breast Scanner Appeal last year with considerable helpful local media coverage, Bolton is very 'breast conscious' as is 891 reflected in the increased number attending the breast clinic and now would be the best possible time to introduce such a scheme. It is immensely encouraging that the health professionals in Bolton are aware that a screening system will not work unless a higher response rate is achieved.

We also know from experience with the cervical cancer programme that GPs have a key role to play in encouraging women to be screened, supported, of course, by appropriate health education. I was delighted to learn of the interest shown by GPs, as well as by women patients in Bolton, which suggests that all concerned would accept their responsibilities in that way.

The Forrest interim report drew attention to a most important constraint. It stated: To assess mammographic abnormalities and to reduce biopsies to a manageable number, expert diagnostic services are necessary. These include clinical examination, additional mammography, untrasonography and fine needle aspiration and cytology. These require the availability of a multidisciplinary team including, surgeons or other clinicians, radiologists and histopathologists skilled in the management of women with early cancers. These expert services are not generally available in the National Health Service at the present time. For that system to be successful, screening and subsequent assessment and diagnosis and treatment would require expertise of a very high standard. We should need to build on the existing expertise, and I note Mr. Peel's assertion in his letter from which I have already quoted: We have the expertise in Bolton to run such a scheme.

I am delighted to learn that Bolton believes that it has experienced staff in the relevant disciplines. Indeed, Bolton has a Health Service of which it can be very proud. As my hon. Friend the Member for Bolton, West mentioned, more in-patients are receiving care at the moment. In 1982, some 32,500 in-patients were cared for. That figure had risen to 35,289 in 1985, and that represents an 8 per cent. increase. Day cases have risen in that time from 3,900 to 4,400 and day patient attendances have risen from 16,900 to 21,900. Similarly over that period, out-patient attendances have increased from 174,000 to 200,000 and that is a 15 per cent. increase.

Those increases have occurred without an enormous increase in resources. The allocation of gross revenue expenditure in 1982–83 was £32,719,000. The figure this year is about £38,700,000. That is not an enormous increase, especially considering the demands on the Health Service in an area such as Bolton. The Bolton area has done extremely well with the money that has been allocated.

I listened with great interest to the suggestion made by my hon. Friend the Member for Bolton, West that an inexperienced district health authority might be linked to an existing centre of excellence. In his letter to my hon. Friend the Member for Bolton, West, Mr. Peel stated: We would suggest a phased introduction of a mammography scheme using Bolton as one of the pilot Districts, would be the most practicable and cost effective way both of testing the Forrest Report's recommendations and practicability prior to wider application. We would strongly suggest that if only 'centres of excellence' are used then little will he learnt in the management sense, and many of the problems that have occurred in trying to produce a workable national cervical call and recall screening service would be experienced yet again. 892 Mr. Peel continues in his letter to state: There are 13,600 women in the 50–60 age group in Bolton which means approximately 100–120 mammograms a week using single oblique view only. If linking the Bolton district to another 'specialist centre' for the purpose of the trial would help the learning process we would be more than happy to do this.

I have made informal inquiries of the regional health authority which would be the appropriate body to decide these matters. The RHA praised the excellent work that has been done in connection with the appeal which involved my hon. Friend the Member for Bolton, West falling out of an aeroplane, as he said earlier. The RHA informed me that for approximately the past two years there has been an appeal in the Bolton district to raise funds for equipment for breast cancer screening. The lady who launched the appeal originally suffered from that disease. It was anticipated that the campaign would raise approximately £25,000, but due to public interest, arid press and media support, approximately three times that amount has been raised.

One mammography unit, a Mamex DC, was purchased in 1985 at a cost of about £26,000. It is intended to purchase a Mamex DC Mag, a rather more expensive version of the DC. The Department has evaluated this unit and eight others, and the working party will report in April.

I am sure that my hon. Friend would wish me to say how much everybody appreciates the enormous effort that has been made by all the people in Bolton. On behalf of all the people concerned—clinicians, professionals and local people — I congratulate the people of Bolton on raising this considerable sum of money — three times more than was expected. I know that they are continuing their fund-raising efforts. We are delighted to see how much support local people are willing to give to the Health Service. By so doing perhaps they express the gratitude that many people feel for the service that they get from our hospitals, clinics and other units.

The region goes on to say—and this must be the last word—that due to public support the clinicians in the district have been prompted to carry forward their interest to start a local mammography scheme. As the public interest is already founded in the district, they feel that they are in a good situation for a pilot scheme. However, the district health authority is concerned about starting the scheme not knowing from where future revenue moneys could be obtained and it is therefore awaiting the recommendations of the Forrest committee.

We shall take carefully into account what my hon. Friend has said. We are delighted to see his commitment and that of all his constituents and the professionals working in the Health Service to the Health Service. It is nice to see people who want to do more and do better for the Health Service by helping to raise the money I am delighted that we have had this opportunity to discuss this important subject and I shall ensure that the issues raised are taken carefully into account when decisions are made.