§ Mr. Malcolm Chisholm (Edinburgh, Leith)
I shall first explain why I am introducing a debate on this distressing subject. First, in purely chronological terms, an all-party group on breast cancer was formed about one year ago today. The hon. Members—including my hon. Friend the Member for Halifax (Mrs. Mahon) and the hon. Member for Rochdale (Ms Lynne), who are present—who were instrumental in setting it up were rightly determined that the group should not consist only of women. I think that that is why I was urged to attend meetings and was installed as secretary.
I have attended all the group's meetings. A string of experts have talked to the group over the past year to explain the problems and issues involved in breast cancer. We have all been struck by the unanimous message given by those experts, and it is that message that I and others want to relay today.
The second reason for the debate is a particularly Scottish one. Half way through last year, a campaign was formed in Scotland called the Scottish Breast Cancer Campaign. It has been a truly remarkable campaign; it was begun by a woman of tremendous drive and determination called Audrey Jones. With great energy and organisation, she created a network throughout Scotland that has campaigned on breast cancer services and research. It is on those two issues that I want to focus this morning.
The network's efforts culminated last Tuesday in a magnificent lobby of Parliament and a march on Downing street, with a petition of more than 200,000 signatures, obtained in less than six months. That was merely the end of the first phase of the campaign and the group is now determined that the campaign should link up with groups in England—it wants a United Kingdom campaign. That is why I am pleased that today's debate is on not just a Scottish issue, but a United Kingdom one. The problems and challenges are the same in Scotland, England and Wales.
§ Dr. Norman A. Godman (Greenock and Port Glasgow)
I fully accept what my hon. Friend says about this being a United Kingdom-wide debate, but is not it deeply disappointing that there is no Scottish Office Minister present to listen to it?
§ Mr. Chisholm
I would have to agree with my hon. Friend on that, but we shall see what the Parliamentary Under-Secretary of State for Health, the hon. Member for Bolton, West (Mr. Sackville), says. I wrote to the Scottish Minister responsible for health, who is in another place—which always creates problems during Scottish health debates—and suggested that he should have a word with the Under-Secretary of State. I hope that he has managed to give at least a brief message to the Minister who is to reply.
As I learnt more about the subject, I became more aware of the scale of the problem. I was immediately struck by the horrendous statistics on breast cancer in this country. I learnt that one in 12 women is likely to develop it and two thirds of those women will die. According to the chief medical officer, the survival rate here is worse than in other European countries and north America. The mortality rates for breast cancer in the United Kingdom 936 are the worst in the world. Another stark fact that drives the message home is that breast cancer is the single biggest killer for women between the ages of 35 and 54. A sobering and shocking thought is that, in the course of today's one-and-a-half hour debate, three more women will die of breast cancer.
It is not just the statistics that are horrendous—we have all heard terrible stories about the contrasts in treatment that women receive. We hear of misdiagnoses, long waiting times for women being referred for initial diagnosis and inadequate treatment. Balanced against that, we also hear of excellent treatment in many of the breast cancer units, such as that in my home city of Edinburgh.
The stories about things going wrong are not just media scare stories. The fundamental message given to the group by the experts was that there is a tremendous unevenness in the treatment received by women. That is the key message that the experts have given to us—they want something done, and it is up to us as politicians to take up that message and do something about it.
One of the experts who spoke to us was Professor Karol Sikora, professor of clinical oncology at Hammersmith. He has expressed the problem as follows:Britain's high death rate for breast cancer is not due to lack of medical knowledge, but to bad management. America has a higher incidence of breast cancer—one in eight of the female population. But proportionally a staggering 50 per cent. fewer women die. The difference is that in America diagnosis and treatment are organized better.In Britain, surviving breast cancer is a lottery. The recent mortality-rate 'atlas' released by the Department of Health shows shocking geographical variations.The problem can be considered in terms of when people are referred for treatment and, more importantly, where people are referred for treatment. There was an example of the time problem in Scotland recently at Ninewells hospital in Dundee. Due to a staff shortage, some women had to wait three months before they were seen for an initial diagnosis—because of the campaigning in Scotland, that problem appears to have been sorted out. Women must be referred promptly once there is a suspicion that something is wrong.
The issue of where women are referred is even more important. According to the experts who talked to us, the key issue is whether women go to a specialist unit where there are experts who deal with breast cancer on a regular basis. The experts said that the most alarming factor was that so many women are still referred to general surgeons or medical staff who do not deal with the specific problem for a great enough proportion of their time. The experts explained that that was the fundamental problem in the organisation of breast cancer services.
I was alarmed by the statistics for some—I think, two—Thames regions. Only 20 per cent. of women referred for breast cancer surgery went to hospitals where more than 100 women were operated on in a year. Some 25 per cent. went to hospitals where between 75 and 99 women were dealt with, 20 per cent. went to hospitals where between 50 and 74 women were dealt with and 22 per cent. went to hospitals where between 25 and 49 women were dealt with. Some 9 per cent. went to hospitals where between 10 and 24 women were operated on for breast cancer.
I asked for figures for the whole of England and Wales this week, but was told that they were not available. I received figures for Scotland and they show that the scale of the problem is not quite so dramatic there. However, 937 we know that many women in Scotland go to general surgeons who are not used to dealing with people who have breast cancer.
It is the experts who are telling us all that. Some medical practitioners are saying that some of their colleagues should not deal with breast cancer because they do not spend a sufficient amount of their time dealing with it. We are told that half of women are referred to general surgeons when they should be referred to specialists. That is the core of the organisational problem that has to be tackled. One result of that is that the treatment that women receive is not as good as it should be. Without getting too technical, I can give one example of that.
I am told that when women are operated on, lymph glands should be sampled routinely. It is staggering that 50 per cent. of women under the age of 50 who should have such sampling do not get it. We hope that that will change. We are told that women under 50 should be given chemotherapy routinely, but the experts tell us that that often does not happen. The problem has been graphically described to us.
The answer has to some extent been taken on board by the expert advisory group on cancer set up by the Government. It has come up with the model of cancer services centralised in cancer centres, of which 20 are proposed for England and Wales, and cancer units, of which a much larger number is proposed. I thought that the same model was to be introduced in Scotland, but when I wrote to the Minister of State, Lord Fraser of Carmyllie, about the matter, he said that the model might not be appropriate. At present, we have five cancer centres and no cancer units. I believe now, however, that the Scottish Office is beginning to take the problem on board. In Scotland, we certainly need a large number of cancer units to complement the five cancer centres.
§ Dr. Godman
I am given to understand that Lord Fraser, who is the Scottish Office Minister with responsibility for health, is to appear before members of the Scottish Grand Committee to he questioned on health matters. Perhaps that would be an appropriate moment to question him more closely on this important subject.
§ Mr. Chisholm
My hon. Friend's point illustrates to our colleagues the difficulties that we have in Scotland in questioning the Scottish Minister responsible for health.
The best general structure of cancer services has been agreed, but specialised breast units are needed within it to complement the cancer centres. The British Breast Group has published a study and argued for specialist breast units. It said that they should be located either within the cancer centres or within the cancer units. So everyone knows what the correct model is.
Within the specialist breast units, surgeons, radiologists, oncologists, nurse specialists and others would all work in co-operation in teams. It has been agreed that that is the correct model, but implementation of the model may well be another matter. There are two sets of problems with implementation. They are resource problems and problems connected with the internal market. We do not want to be too party political on this issue, but we must face up to the fact that the internal market creates obstacles.
§ Mrs. Alice Mahon (Halifax)
My hon. Friend was at the same meeting that I attended, at which consultants and 938 professors told us that the abolition of the regional health authorities was a great worry because they had played such a crucial role in setting up the screening programme. The internal market is fragmenting the programme.
§ Mr. Chisholm
I am glad that my hon. Friend has raised that purely English issue. I have had correspondence with the British Medical Association about the effect of reorganisation on screening. I hope to read some of its letter later to convey that particularly English problem.
Professor Karol Sikora has said that about £300 million would be needed to provide the required number of specialists, including breast care nurses, and additional equipment for the units. That nettle will have to be grasped if the model is to be implemented. As for the internal market problems, Professor Sikora made the point that the development of the internal market meant that purchasers were less likely to buy from specialist units because they tended to be more expensive. That issue will come up next week when the Cancer Relief Macmillan Fund brings out a directory of services to be provided to GPs so that they can refer patients to the best unit. There will be a problem in whether health boards have contracts or would be willing to have such contracts with those units.
There are also problems on the provider side. Many provider units may not want to lose their breast cancer work as part of their general surgery. In a private conversation, a leading consultant told me that, particularly in England, many general surgeons wanted to keep the work because it was part of their private practice. That is another issue that will have to be tackled. It is important that breast surgery and breast cancer treatment should be on separate contracts. They should not be part of general surgery contracts. They should be contracted for separately. That is another recommendation of the British Breast Group report.
We are told that one of the differences between Britain and other countries in its provision of breast cancer services is that we have far fewer oncologists, both clinical and medical. That is another funding issue, which is also connected to the issue of special units. I have been told in answers to parliamentary questions to which I have received replies this week that the number of oncologists has not increased very much. There are slightly more for the whole of the United Kingdom. We now have 272 clinical and 68 medical oncologists. To put that into perspective, I am told that there are 2,500 medical oncologists in France.
We have also been told that each clinical oncologist in Britain sees 560 new patients a year. The recommendation is 350. We are told that in America they see 200 and in Norway they see a staggering figure of only 75. So there is the problem of the number of oncologists, who are essential to the work of breast cancer units and general cancer units and centres.
Apart from the problem with the number of oncologists, there is a problem with their funding. That became an issue in Scotland last year. As a result, I tabled a question about the matter. I was told that seven out of the 11 medical oncologists in Scotland last year were funded by charity. I was not being mischievous when I tabled another question last week. I simply wanted to know how much the position had changed by now. I am told that the Government think that five are funded by charity out of 939 12. Something strange is going on there which will have to be investigated. At least the Scottish Office had an answer. The English Department of Health does not know how many oncologists are funded by charity. We have been told by the experts who came to our group that it is a large number. That is a scandalous position, given the key nature of their work in the model of cancer treatment that is proposed.
Apart from their work in treating breast cancer and other forms of cancer, medical oncologists are essential for research. Research is the second aspect of today's debate. Once again, we are confronted by the two problems of resources and the internal market. On the resource side, the experts—I keep referring to them deliberately because all that I know has been told to me by the people who know about those matters—are unanimous in what they say. They tell me that in Britain uniquely a large proportion of cancer research is funded by charity.
We have been shown graphs, which show that in other countries research is funded mainly by Government money, with a little charity money. In Britain, it is the reverse. That is a fundamental problem, not only because it is the Government's responsibility to fund research, but because charitable funding in the nature of things is short term. The experts say that they need long-term funding. Charitable funding also fluctuates. I noticed recently that the funds of one of the cancer charities fell by £6 million last year. That creates problems for research.
I have tabled some questions on breast cancer research in particular. It appears that there was an increase in funding between 1991–92 and the following year. Some money—about £700,000—came from the Department of Health and less than £100,000 came from the Scottish Office. Proportionately, however, that was a greater contribution than that of the English Department of Health. The Medical Research Council money, being the main source of Government funding, was £1.6 million in 1991–92 and £3.1 million in 1992–93, which appears to be progress. However, I note that last March the Minister responsible for science said, in referring to the £3.1 million:Included in that figure was £836,000 which was directly related to basic laboratory research into cancer."—[Official Report, 29 March 1994; Vol. 240, c. 680.]Of course, that is vital work, but I wonder whether the basis for the figures has been changed from year to year.
I do not want to quibble, but we need to put into perspective what £3.1 million means compared with the sort of money that is needed. A graphic illustration of that is the fact that the Royal Marsden hospital is trying to raise £15 million for just one project. Professor Baum, Marsden's professor of surgery who deals with breast cancer, told us that that research was absolutely essential. He said that it was to look at the molecular biology of normal cells and the genetic defects that result in their transformation into cancerous cells. He said that that was the most hopeful area for a research breakthrough. The context, therefore, is that £15 million is needed just for the one project, yet total Government funding for breast cancer amounts to only just over £3 million. There is obviously a funding problem.
940 There is also an internal market problem with research. An article in the British Medical Journal on 13 August 1994 by the United Kingdom Co-ordinating Committee on Cancer Research showed the results of a survey of contributors to clinical trials in breast cancer. The survey found that half had difficulties, many of which sprung from the nature of the internal market in the health service.
The article stated:The financial imperative from a market based NHS to avoid the 'unnecessary' expense in undertaking a trial is the basis of real conflict. If, for example, clinicians really are uncertain about which of two treatments is best, why not settle for the cheaper? But the NHS has a commitment to improve treatment. This requires a commitment to undertake and complete trials, accepting that such a strategy carries financial implications …A problem now being encountered"—and this repeats something that I mentioned in a different context earlier —that is a direct result of the new purchaser-provider agreements is that patients are being treated in local hospitals rather than being referred to specialist centres. In recent years several studies have shown that there is a survival advantage if treatment is given at a specialist centre, and this advantage will be lost if contracts are increasingly given to local hospitals that lack specialist cancer services. Also, as it is generally the specialist centres which enter patients into trials a decrease in referrals to cancer centres means that there is a reduced pool of patients being invited to participate.The article explains that there are also problems because of the new set-up with trusts relating to insurance, the storing of samples and increased paperwork. Leading British clinical researchers have expressed concerns about the new health service set-up as well as about the underlying funding problems.
I wish briefly to raise two aspects related to research. One area where research is required is screening. That has already been mentioned by my hon. Friend the Member for Halifax. There are many issues relating to screening. A British Medical Journal article just two weeks ago said that it is time for Britain to screen women over 50 every two years. Research has shown that, among women being screened in their third year, the number found with cancerous growths was much the same as the number among the unscreened. In other words, those women should have been screened after two, not three years.
§ Mr. Bernard Jenkin (Colchester, North)
Surely even every two years is not adequate for screening. What is really needed is a comprehensive public education programme so that women constantly screen themselves. A lump in a breast can become fatal within a few weeks of it first appearing. We need a huge public education programme to raise the profile of the issue, so that women constantly screen themselves. There is no substitute for that.
§ Mr. Chisholm
I am sure that the hon. Gentleman has a point, but it cannot replace the screening programme. We should follow the example of other countries where a two-year interval is normal for women over 50.
The article said that better results would be obtained if two mammograms were taken—indeed, a 20 per cent. improvement in the detection rate. It said that there would be another 15 per cent. improvement if two radiologists read the results. The article also said that considerable financial and staffing implications were involved in bringing about such improvements.
941 Another issue is screening of the over-65s. That matter is often forgotten. Although the largest number of women who develop breast cancer are over 65, there is no routine screening for them. There is also the issue of high-risk young women. I am aware of the debate about screening young women—I will not go into that now—but something must be done to ensure that such women are looked after properly.
My hon. Friend the Member for Halifax mentioned the effect of the Health Authorities Bill on the screening programme. I feel duty bound to read out a brief excerpt from a letter from the British Medical Association:We remain unclear on how the programme will operate after HA reorganisation …All cancer registrations and efficient data handling depend upon integrated computer systems. The complexities and financial implications of replicating this at district level are considerable. Devolving the programme down to local level will demand many more personnel in order to make medical and clinical audit meaningful. It is unlikely to be cost-effective at local level and clinical audit between health authorities and providers is bound to be compromised.There is great concern about the environmental causes of cancer. A recent television programme featured the pesticide lindane. I and other hon. Members wrote to Ministers about that. Lord Fraser, the Scottish Minister responsible for health, said that the Advisory Committee on Pesticides was currently reviewing lindane's agricultural uses. I hope that the review will be completed speedily, because organochlorine pesticides are banned in most countries. Lindane is the only one still widely used in this country. Indeed, its use has doubled during the past seven years. I hope that the experts will speedily look at the evidence from Israel, which was presented in the television programme, and also at evidence from America, which suggests that lindane stimulates the production of a hormone that damages DNA.
I want to explain how America has dealt with the problem of breast cancer. Figures that I gave earlier show that although breast cancer occurs more frequently in America—one in eight women rather than one in 12—proportionately, 50 per cent. fewer women die. Yet America, with a so much better record than Britain, had an enormous campaign. I like to compare it with our Scottish campaign, although it was on a different scale. Proportionately, of course, the two campaigns are quite similar because the American campaign collected 2.5 million signatures, while the Scottish campaign has already collected 200,000—so in terms of population, the Scottish campaign has probably done better.
The American campaign was thrown on President Clinton's desk and he took action immediately. His Health Secretary convened a conference, which established a national action plan for breast cancer. My hon. Friend the Member for Halifax may say something more about that later. Part of that action plan was a shifting of $210 million from the defence budget to breast cancer research. The British Government should look to that example. This country's problem, as I have explained, is more serious than America's, so a correspondingly greater response is required of our Government.
The Scottish campaign and its members are my inspiration and guiding light on this issue. Their petition asked for more resources for specialist units and for more Government funding for breast cancer research. They are determined to continue their campaign and to extend it 942 throughout the United Kingdom. With the help of several hon. Members, that is what they intend to do in the months ahead.
I know that there is a great deal of activity on this front. The Select Committee is investigating the matter; my hon. Friend the Member for Halifax will introduce a Bill on this very subject. We are determined that this most distressing issue gets the response from the Government that it most assuredly deserves and requires.
§ 12 noon
§ Mr. Piers Merchant (Beckenham)
I compliment the hon. Member for Edinburgh, Leith (Mr. Chisholm) on drawing the House's attention to the serious subject of breast cancer. As he rightly said, the incidence of breast cancer in England and Wales is the highest in the world; it is in fact five times as high as in Japan, causing about 15,000 deaths a year. It is interesting to note the distinctly different impact of breast cancer on the various socio-economic groups in this country: there is 50 per cent. more breast cancer among group 1 women than among women in groups 4 and 5.
The hon. Member for Leith was right to draw attention to the need for improved breast cancer services. I entirely agree with that objective. He was also right to draw attention to the problems that there have been with treatment and care. We should not, however, underestimate the difficulties of judging the best course of action at any particular time. Many of these problems have arisen simply because of a lack of knowledge or because of faulty medical judgments—entirely understandable, but based on limited scientific knowledge of the illness.
The hon. Gentleman was right to juxtapose the issues of services and research, because the former so crucially depend on the latter. It was to be regretted that he did not draw enough attention to the real progress that has been made and to the distinct improvement in the services that are available. First and most important is the national screening programme. This country was the first in the European Community to bring in comprehensive national screening—an important international first, and a sign of the importance that the Government attach to dealing with the problems posed by breast cancer.
The hon. Gentleman also did not draw enough attention to the Calman report, published last year, which stressed the need for reorganisation and a national programme to ensure that the swiftest, most effective forms of treatment were brought to bear on women who were found to have developed breast cancer. The report distinguished between three important levels of care. First, it stressed primary care; secondly, the need for designated units; and, thirdly, the need for designated cancer centres. Speaking about the importance of specialist centres, the hon. Member for Leith did not give sufficient emphasis to the relevant part played by primary care services and by the designated units at a more local level, which are an important part of the process.
The hon. Gentleman was right to stress the need for similar standards of care throughout the country. He was right to focus on the deficiencies in that area, but I was not sure that his simple emphasis on centres of excellence was necessarily the best approach.
The Calman report's conclusions have already been acted on in many areas. I should like to draw the House's attention to the real progress that has been made in the 943 Bromley area, which includes my constituency. Bromley hospital is starting its first breast care clinic later this month. It will be a multidisciplinary clinic, and there will be one surgeon who is already there and a new one who is a specialist in breast cancer. At the same clinic there will be a breast cancer specialist oncologist, and a nurse counsellor who has been specially trained for the purpose. Finally, there will be a personal prosthetics expert on hand to help women who may need support.
All that specialist provision will be available at one local clinic. That is a big step forward. It is important to ensure that, while the regional centres of excellence are available when needed, there are also local, accessible services to provide a quick response for women who have tested positive or who have been referred on by their GPs. This saves waiting and anxiety, because it enables testing and results to be acted on locally and swiftly.
I am pleased about this step forward in my area, and I hope that it will be repeated across the country. Apart from producing a great improvement in care, it will also enable much of the later treatment to be carried out locally in a co-ordinated fashion. There will be facilities for performing chemotherapy and some surgical procedures, but when necessary patients will automatically be referred to one of the nearby regional centres of excellence.
There is no question of any patient being given second-rate treatment or being diverted to some secondary, poorer tier of service instead of to the regional centre if that centre is the right place for the patient. The clinical judgment on where a patient should be treated, however, will depend on how her form of cancer has presented. As most people involved in the field will know, that will vary considerably from one case to another.
I should like to refer briefly to the important screening programme. The Forrest committee reported in 1987 that screening was the single most important way of reducing deaths from breast cancer, and predicted that as many as 25 per cent. of deaths from it could be prevented by the year 2000, giving an average 20 years more life to the people who were afflicted. If everyone called attended screenings, 40 per cent. of deaths could be prevented. That was why breast screening was introduced nationally.
I should like to enter a few words of caution, although I do not want them misinterpreted, because I fully support breast screening and believe it to be important. It would be wrong to think that screening is a panacea and that no problems will result from it. There are four or five areas of difficulty, of which the first is false expectation. The fear is that, with the availability of universal screening, people will relax and think that the problem has been solved: because screening is available, early detection is possible, so a cure will follow. That is of course not correct. A cure does not always follow, even with very early detection. There is of course a much greater statistical chance of a cure, but it is still limited.
Secondly, there is the difficulty of unnecessary treatment. Any suspected form of cancer detected at an early stage is the subject of medical uncertainty as to whether it will develop into malignant cancer or turn out to be benign. There is thus the danger of unnecessary treatment following on from mass screening. More research needs to be done on that; it would certainly not he beneficial to put women through the trauma and pain of treatment if that treatment is later found to be entirely 944 unnecessary. It is also a complete waste of resources when money and expertise are devoted to putting right a problem that was not there in the first place. Important research is required in that respect. There is always the problem of cancers being missed because of technical limits on screening processes. However efficient they may be, because cancer varies from individual to individual some cases will be overlooked. Serious failures can occur in the computerised administration and follow-up systems, and much attention should be paid to making them as perfect as possible. We must be realistic, however, and accept that perfection cannot be achieved in dealing with so many people, and that there will always be an element of failure.
The extent of screening, medical judgment, the age of screening, and how frequent it should be—a point made by my hon. Friend the Member for Colchester, North (Mr. Jenkin)—type of screening, the radiation and other risks and other forms of care should be researched. Over the years, experts have changed considerably their assessment of appropriate treatment—whether there should be minor or major surgery, chemotherapy or radiotherapy and, if so, which comes first.
The hon. Member for Edinburgh, Leith (Mr. Chisholm) was right to stress that research is the most important factor in tackling breast cancer. Research will dictate the most effective action in detection and treatment. Let us hope that it will ultimately produce answers to the causes and development of breast cancer, and that steps can then be taken to prevent it. After all, prevention is always better than a cure.
§ 12.11 pm.
§ Mrs. Alice Mahon (Halifax)
I congratulate my hon. Friend the Member for Edinburgh, Leith (Mr. Chisholm) on securing his Adjournment debate. He is a hard-working member and secretary of the all-party group on breast cancer. I am joint chair with the hon. Members for Rochdale (Ms Lynne) and for Congleton (Mrs. Winterton). Its members have been on a learning curve for 12 months, but the group is a success.
I became more interested in the subject in 1992, when I was visited by two breast care nurses who were worried about the care and service given to suffers in the Yorkshire region. I commissioned a survey of the 12 regional health authorities in England to obtain a better picture. They were asked to provide details of the number of their breast clinics, breast care nurses and support groups by district, to assess provision and the contribution that each region was making to the national screening programme.
It is important to understand the scale of the problem. The British Breast Group's latest statistics show that the incidence of breast cancer in the UK is 25,000 cases per annum, which is among the highest in the world. Mortality is also high, at 16,000 deaths a year. Apparently, the survival rate in this country is poorer than in other European countries or the United States. The cause of high incidence and poor survival is unknown, but the latter may partly be attributable to poor management of the disease, which should be seriously examined.
According to research, the death rate from breast cancer has remained virtually unchanged over the past 50 years, and women are paying the price. They are the foot soldiers of that dreadful disease. Their suffering is 945 matched only by that of their families after the premature death of a sufferer. As my hon. Friend said, it is important not to view breast cancer as just a woman's disease because it brings devastation and grief to families affected by a sufferer's early death.
I pay tribute to Jacqui Bokowsky and my hard-pressed staff for their work on my report, which left me convinced that the screening programme saved lives because the Government acknowledged the importance of funding it and set aside £25 million.
The other important aspect was the national nature of the programme. There is great concern about the disbanding of regional health authorities, which played a crucial role in screening. They acted as the strategic authorities and did a superb job. I do not want to seem grudging, because I congratulate the Government on implementing that programme, which was an important step forward. I should like it to be extended to provide screening every two years and for the over 65s.
Unfortunately, four regional authorities did not complete the questionnaire and so our data are not comprehensive, but it was still a worthwhile exercise. The Library also provided statistics. Our findings were shocking. Some regions provided an excellent service while others were poor. It became clear that the service was fragmented, and geographical location had a bearing on the treatment that patients received. As one might expect, public transport problems and widespread poverty in some regions prevented some women from taking full advantage of the facilities on offer. As my hon. Friend said, some treatments vary widely.
In some inner cities, the only provision was the local out-patients department. The north-west region had breast clinic provision for only 0.29 per cent. of women per 100,000 population. In the Yorkshire and north-west Thames regions, the figure was 0.85 per cent. The survey also revealed that breast care nurses—one third of whom are provided by the Macmillan fund—form the mainstay of care groups and after-treatment. Their work is vital in providing continuing care to patients in hospital, but also in the community—to patients, their husbands and families. Those nurses are highly valued by women. Members of Bosom Friends, a support group in Bradford—some of whose members are very young—told me that their breast care nurses, in particular Norma Russell, make a tremendous difference to their lives. She works hours of overtime for nothing. Should we skimp on such a valued service?
Cuts have been made in the service, even though the incidence of breast cancer is as bad as ever. The working party's report was endorsed by the British Breast Group in July. It is adamant that services could be improved by grouping them together in specialist units. It states that all patients with breast disease should have access to the highest-quality care. It emphasises the importance of accurate and timely diagnosis, appropriate treatment and follow-up, effective communication, which means breast care nurses being in place, access to other specialist facilities and the provision of high-quality services between specialists from different disciplines. They include surgery, radiology, pathology, medical, clinical oncology, nursing and palliative care. It is essential that those multidisciplinary teams are at set up together in specialist units.
946 There will be a problem, because purchasers might be tempted to buy from a provider who is buying in the service of an oncologist for just a few hours a week. It will be nothing like as good as a specialist team. We know that because of the experience of the specialist hospitals in London, which are funded only in the short-term and are worried about their future. For anyone with an interest in the subject, the working party's report is well worth reading and it contains excellent recommendations.
Next week, I shall introduce a ten-minute Bill. It is an attempt to persuade the Government that we need a national action plan, such as that in America, to tackle this killer disease. The all-party group has had tremendous help from specialists in the past 12 months and, above all, from the women who have suffered from this dreadful disease. They want and deserve a national action plan. I hope that, when I present my Bill next week, the Government will take note of what they are saying to us.
§ Lady Olga Maitland (Sutton and Cheam)
Last week, I visited the Cancer Research Institute, which has a world-class reputation for research and is based in my constituency. It works in close partnership with the Royal Marsden hospital.
I was given a guided tour by Professor Peter Garland, the chief executive of the institute, who leads 600 staff, making it the largest research institute in the world dedicated to the conquest of cancer. In particular, it has done excellent work in connection with breast cancer. It has recently pioneered important genetic work allowing it more accurately to identify those women at risk from breast cancer, who would consequently need special screening and preventive measures. It has been discovered, for instance, that some women are likely to have more than one gene, inherited from the family, which predisposes them towards the development of breast cancer. Indeed, it has been found that such genes are responsible for 5 to 10 per cent. of cancers, or about 1,000 of the 15,000-plus people who die each year in the United Kingdom from that disease. Perhaps a woman who has been identified as being at risk from breast cancer could be put on a trial new drug called Tamoxifen. It is part of a large, international trial, which, I hope, will substantially prevent the disease from starting in the first place.
The institute has a very exciting programme of work in curative measures for other areas of cancer: ranging from treatment of testicular cancer, 90 per cent. of which is treatable; to tremendous advances in treating ovarian cancer; to developing a vaccination to prevent and eliminate cancer of the cervix; to treating childhood leukaemias, and much other work. One will understand why I am so enormously proud that the institute is in my constituency.
The tantalising thing about success is the intense frustration which is felt: in wanting good work to continue, work which, of necessity, is held back through the constant battle against other competition for more resources. The real question that I ask the Government is: are they really giving essential research the full support that it undoubtedly deserves? I congratulate the Government on making the United Kingdom the first country in the European Union to develop and introduce breast cancer screening, but it is no use embarking on further major cancer screening programmes if the follow-through, in terms of research and treatment, is not 947 given the fullest possible back-up, otherwise one will be faced with only half a loaf—the cancer identified but not adequately treated. Successful treatments come about only by a heavy commitment to research.
The Medical Research Council works wonders, but it has a finite budget of around £210 million and must cover all diseases. The MRC is excellent for fundamental work, much of which is generic, but quite simply it does not have the resources to carry everything through to application. The university sector is mainly supported in terms of educational activities. Cancer is but one subject or specialty among many, and few universities can put together a critical mass for research.
The cancer charities raise and spend some £200 million a year, mainly on research but also to improve services. Without them, the quality and extent of research and service in the United Kingdom would be greatly weakened. I am not at all happy at the thought of cancer charities substituting for, rather than complementing, Government support. In the case of the Cancer Research Institute, £25 million is required to run 600-plus staff.
The Cancer Research Institute receives just £2.5 million from the Higher Education Funding Council for England; even it recognised, by its own calculations and procedures, a shortfall of at least £2 million, but it has refused to do anything about it, except for vague promises in the future. It is not acceptable to argue that if the council allocated more resources to the institute, it would be to the detriment of other universities, the great majority of which, by the HEFC's own assessment, rate less well, often markedly so. That shortfall is a substantial handicap to the institute's work. It makes up the shortfall with charitable moneys, which go towards heat, lighting and sundry expenses rather than the direct research for which it is intended. More than that, the HEFC is contradicting its own stated policy. It should be buying the very best research that it can. The fact is that it declines to do so in the case of the institute.
As Sir Peter Swinnerton-Dyer, the former chief executive of the Universities Funding Council, said:Within each subject, it must therefore be right to concentrate most of the research funding in those departments that are likely to provide the best value for money.In my view, he is absolutely right. It is very short-sighted to set up a ambitious screening programme without a fully supported research programme to give the very best possible treatment to all patients, otherwise one would be putting the cart before the horse by screening without the back-up research facilities to ensure that a sick woman becomes well or that we can prevent cancers from developing in the first place.
§ Mr. Jeremy Corbyn (Islington, North)
I shall be brief, as hon. Members wish to speak in the debate.
We should all put on record our thanks to my hon. Friend the Member for Edinburgh, Leith (Mr. Chisholm) for securing the debate and for speaking so well on the subject. As the report of the British Breast Group working party said:Breast cancer mortality in the UK is the highest in the world. The reasons for this are poorly understood, but the wide dispersal services for breast cancer patients may be a contributing factor and certainly impedes clinical research.948 If ever there were a brief description of the horrendous problem and of the need for the Government to introduce a national programme as quickly as possible, that is the summary of it. I hope that, next week, the ten-minute Bill to be introduced by my hon. Friend the Member for Halifax (Mrs. Mahon) will get a clear run in the House, and that for once a ten-minute Bill will be successful in changing policy.
The reasons for breast cancer are poorly understood and are not evenly shared between different socio-economic groups. Indeed, if anything, it appears that the higher income groups suffer slightly more greatly from breast cancer, but they also have greater longevity anyway, so there may be a connection there. The incidence is much higher in western Europe and north America than in what we choose to call third-world countries. There may well be environmental and dietary connections. There are an awful lot of possible connections that need to be examined as rapidly as possible. In the United States, President Clinton responded quickly and magnificently to the request for a national action plan, and that is something for which ire—as must all the men and women throughout the United States who campaigned for it—be applauded. President Clinton should also be congratulated on the fact that he was prepared to shift money from the defence budget to a national action programme. I would love to think that the British Government will see the error of their ways in financing yet another Trident submarine and start shifting those resources into health care; we should all be better off as a result.
The seminar held in the House in December was, I think, very valuable: I could not attend, but I have read reports of it. A recurring theme was the need for multidisciplinary teams to work together from a single specialist centre. All the evidence suggests that the dispersal of services and the lack of centres of excellence lead to inadequate care. Moreover, they lead to differing standards of care: the system that decides to whom a patient is referred is almost a lottery.
My hon. Friend the Member for Leith cited the Thames regional health authority. There is no earthly reason why the health authorities—all surrounding London—should not be able to look to one or two centres of excellence; that, surely, would be better than dispersal of services among certain hospitals. After all, one in 12 women in this country are likely to develop breast cancer, but only 40 per cent. of patients will be able to see specialist oncologists. The average number of patients seen by oncologists in the United Kingdom is 560—the highest number in Europe. The recommended number is only 350. That means that oncologists are overworked; the resources must be spread, and I hope that the Government will act.
One of the problems is that surgeons often have little experience of breast cancer. It is difficult for hon. Members who are not medically qualified to hold forth about the way in which patients are treated by individual doctors, but I feel that there is an overwhelming case for demanding specialist treatment. A surgeon who is a "generalist" is unlikely to have the time or the inclination to become a specialist. Far too many women are having mastectomies which could possibly have been avoided if treatment, or even screening, had been provided earlier.
There are also serious problems with radiotherapy. They have been highlighted by Radiotherapy Action Group Exposure—also known as RAGE—a group of women who have been given radiotherapy for breast 949 cancer. The organisation has heard from 1,400 women; some of the letters that it has received came from the families of women who died not from cancer but from the injuries caused by their treatment. In many instances, it appears that overdosing and serious side-effects were involved. I hope that the Minister will say that his Department is prepared to take an interventionist line, and set up a national action programme that will direct research appropriately and establish regional centres of excellence.
We have been considering the resources that should be made available to women suffering from breast cancer. As we are now in the age of the charter, let me suggest some services that should be available under such an arrangement. First, general practitioners should be able to refer patients promptly to a team specialising in the diagnosis and treatment of breast cancer, including a consultant. The GP should not have to think, "Goodness, what do I do now? Where can I find a specialist?"
Secondly, the patient should be given a diagnosis within four weeks of being referred to a hospital. All too often, GPs in my community tell me that they spend hours on the telephone every day simply trying to refer patients to hospital. My main local hospital, the Whittington, can deal with no new cases—other than life-and-death emergencies in the local population—until April, because of inadequate funding. That in itself is a serious problem.
Patients also need a confirmed diagnosis before they consent to treatment, including surgery. There is still an information barrier between the patient and the medical professions. Every woman should be fully informed of all the implications of every kind of treatment that is available—or not available—before surgery. Patients should have access to specialist breast care nurses who are trained to provide information and psychological support: psychological support is vital to the person concerned, who is undergoing a very traumatic experience.
The national health service should enable patients to meet others who suffer from breast cancer. Too many people must deal with the horror of cancer in isolation. I have encountered cases of people who do not want to tell their families that they are suffering from such a disease: they are unable to share the experience with anyone. Although any promotion of such discussions between sufferers by the Department of Health would not be a medical action as such, I consider that the opportunity for sufferers to meet other patients and former patients is very important—as is the provision of information about support services for patients and their families, who can at least give them support and some understanding.
Breast cancer is a crucial issue on which this country has a dreadful record. We have had a short opportunity to raise that issue today; I hope that the Government will respond by devoting real resources and real action to it.
§ Mr. Bernard Jenkin (Colchester, North)
I greatly appreciate the opportunity to speak, and congratulate the hon. Member for Edinburgh, Leith (Mr. Chisholm) on securing the debate. I also congratulate him and other members of the all-party breast cancer group—to which I belong—on the work that they have done. They have brought much into the open during the debate, and I endorse much of what has been said. As a result, this has been a very useful debate; perhaps we should discuss the subject more regularly.
950 It is difficult to imagine a disease that touches the lives of so many of our constituents. Every Member of Parliament has a direct interest in ensuring that the dreadful figures that have been given are improved. I want to enlarge on points that have already been raised—including, notably, the need for a national plan not just on screening but on research and treatment, along the lines of the model set out in the United States National Cancer Act of 1971.
It is interesting to note that the President himself has a cancer panel, such is the priority that the American Administration attach to the problem. It is, in fact, due to the still rather unfashionable President Nixon that the panel exists; President Clinton merely used legislation that was already on the statute book. We lack any legislation of that nature with which to tackle this huge disease. 'We probably spend less time discussing cancer than we spend discussing AIDS, which—in terms of the number of deaths that it causes—constitutes a tiny fraction of the problem created by breast cancer.
I want to concentrate in particular on the unfortunate group of women who belong to Radiotherapy Action Group Exposure. I became involved in the subject because one of my constituents suffered serious injury as a result of radiotherapy. We are fond of thinking that people who have been cured of breast cancer are fortunate, but a sizeable group of them have been afflicted by appalling and painful injuries of which they were given no warning when they were considering what treatment they should accept and what hope they had of a cure. Something must be done. The injuries occur at different rates, and at different treatment centres. That underlines what the hon. Member for Islington, North (Mr. Corbyn) said about treatment being a lottery: there is a lack of consistency between different centres and different parts of the country, and the chances of injury at some hospitals are far greater than at others—I shall not name any hospitals. No one seems to know why that is.
The women concerned are suffering from very disabling effects. Some, like my constituent, are in constant pain, often so bad that they seek amputation of a limb. The radiation damage to their bodies often requires such amputation, or causes death. No Member of Parliament who has listened to the stories of those women can underestimate the pain and suffering that they experience.
I am able, however, to congratulate the Government on setting up a proper inquiry into the matter. Following meetings with the chief medical officer, the president of the Royal College of Radiologists, RAGE and Professor Karol Sikora, the Under-Secretary of State, my noble Friend Baroness Cumberlege, authorised an audit of brachialplexus neurologically related injuries, to be conducted by Dr. Thelma Bates and Dr. Richard Evans. It started on 1 September 1994 and its aim is simply to find out what has happened and why.
I hope that my hon. Friend the Minister will continue to respond to RAGE's representations. I congratulate the Select Committee on Health on inviting RAGE to give evidence to its breast cancer inquiry. Let us hope that the Select Committee will continue to return to the subject on a regular basis.
951 We are fortunate that we are a generation that talks about the disease, which is prepared to discuss it and to raise its profile. I hope that the Government will continue to respond positively to the representations that are made to them on this subject.
§ Mr. Eric Illsley (Barnsley, Central)
I add my congratulations to my hon. Friend the Member for Edinburgh, Leith (Mr. Chisholm) on securing a debate on this important subject, on which a tremendous consensus appears to exist. I congratulate the all-party breast cancer group on its work. As we have heard, breast cancer is a common and, far too often, fatal disease. The statistics have been rehearsed already, but it is worth confirming that we have the highest breast cancer mortality rate in the world—its incidence is five times greater here than in countries such as Japan. One woman in 11 will develop breast cancer. Sadly, between 25,000 and 29,000 new cases arise every year.
Unfortunately, the reason for the high incidence of breast cancer in the United Kingdom is not fully understood. Obviously, further research is needed into the causes. It would appear that the disease is associated with western developed countries. There are high incidence rates in the United States of America, in Canada and in Europe, and some social and environmental factors have been stated as possible causes, including high-fat diet, hormone treatment, oral contraception, alcohol and stress, to name but a few.
Sadly, as the House has been told, each year between 13,000 and 15,000 deaths occur as a result of breast cancer. That is a grave cause for concern. It is the sixth commonest cause of death in the UK, and the commonest cause of death for women aged between 35 and 54. Clearly, we must address ourselves to prevention, to early diagnosis and, as we have heard, to better treatment. We should also, however, look towards researching the causes of breast cancer. I was interested to hear the comments of hon. Member for Sutton and Cheam (Lady Olga Maitland). The position is so bad in this country that we must deal with it. We cannot rely on charitable funding for research.
Breast cancer was recognised by the Government and included in "The Health of the Nation" White Paper. A target was set to reduce the breast cancer death rate in the population invited for screening by 25 per cent. by the year 2000. The rates have varied from 95.1 deaths per 100,000 of the population in 1990. The target is to reduce that figure to 71.3 deaths per 100,000. Problems still surround the diagnosis and treatment of breast cancer, despite the setting of that target; hence the Government's expert advisory group on cancer, which reported in May last year.
Various opinions exist on the value of a screening programme. The British Medical Journal view of "The Health of the Nation" doubted the efficacy of screening and described the White Paper's targets as optimistic. In 1985, there were 98.3 deaths per 100,000 of the population; in 1990 the figure had reduced to only 95.1 per cent. So there could be some difficulty in achieving the target.
952 The journal suggested that the Government should take other steps. With an eye to this Friday's debate in the House, it stated:Above all else, it"—that is, the Government—should make it clear that it is willing to reduce smoking through legislative means. Only then are screening, diet, information, and counselling kept in proportion.Suggestions have been made that the screening interval is too long, and that an age limit set at 50 is too high. I accept that it has been found that the screening programme is more effective for post-menopausal women—hence the setting of the age level at between 50 and 65. Studies have been conducted, however, into what are known as "interval" cancers, which occur within the three-year screening time. According to a study in the North Western regional health authority, an increased number of interval cancers occurred between screenings.
I acknowledge that, in a circular in January this year, the Government set out guidance on screening, and required screening units to take two X-rays to try to ensure a more efficient screening programme, but perhaps we should begin to consider whether those interval cancers are "new" cancers, or existing cancers that have been misdiagnosed.
Sadly, errors of diagnosis have been made. It seems that errors occur with all screening programmes. In May 1994, all 90 screening units were required to check their clerical systems because of errors. Some 30 per cent. of the cancers highlighted in the study of interval cancers undertaken in the North Western regional health authority were subject to misdiagnosis.
It is clear that the treatment of breast cancer has not been as good as it could be. Many of the problems have been acknowledged—inequalities of treatment, geographically and economically; the low number of cancer specialists; the internal market; the purchaser-provider split and how that impacts on the purchase of cancer care; and women treated by specialists who perhaps have inadequate training or experience in particular cancers, especially breast cancer. We have heard from hon. Members about delays in referrals.
The women who are diagnosed as suffering from breast cancer deserve sympathetic and expert treatment from specialists who are experienced in the disease. The inequalities were exposed by the Thames cancer registry recently. Health Service Journal stated in September 1994:The Thames study highlighted 'variations and inequalities' in treatment and said the chances of a woman surviving the disease were 'likely to depend on where she lives and how well off she is'.That is a disgraceful position, which must be dealt with, and which I understand the Government will deal with when they respond to the expert advisory group.
We have heard that the abolition of regional health authorities will bring about an uncertain future for many screening programmes and cancer registries. I hope that the Minister will assure the House that screening programmes will continue, and that the registries will be able to continue their work under the new regime. That information is crucial to research in this matter.
It is sad that, in this country, five-year survival rates can vary by almost 20 per cent., depending on how affluent the area is where a person resides. That was brought out by the regional health authority study. One 953 can only guess at the variations in affluence that might occur between various parts of the country, north and south. My hon. Friend the Member for Halifax (Mrs. Mahon) mentioned the problems that she had trying to find out what treatments were available in Yorkshire.
I have of necessity to be extremely brief, but I wish to refer quickly to the Macmillan cancer care fund, which last year issued a 10-point programme for breast cancer care. It will also announce an initiative next week which, I hope, will prove successful. As we have heard, the expert advisory group will set up primary care centres and designated cancer units and centres. I hope that the Government will respond as soon as possible to the consultation, which has now concluded. I understand that their response is due early this year.
I hope that, with the Department of Health's initiative and with the various charities involved in research, we can look forward to a comprehensive system for the treatment of breast cancer, something that the country greatly needs.
§ The Parliamentary Under-Secretary of State for Health (Mr. Tom Sackville)
I congratulate the hon. Member for Edinburgh, Leith (Mr. Chisholm) on his eloquent appeal for the highest quality of care and service for women with breast cancer and thank all hon. Members who have contributed to the debate. I share the hon. Gentleman's regret that there is no Scottish Minister here, but I am glad to hear that he will have the opportunity to question the relevant Minister in detail. I assure the hon. Gentleman that the Scottish Office Home and Health Department—like the Department of Health—is committed to reducing deaths from breast cancer as part of the aim to reduce cancer mortality overall.
The hon. Gentleman has very ably led the parliamentary all-party group on breast cancer, which has done so much to make its presence felt in lobbying on behalf of the thousands of women who contract this terrible condition. I therefore appreciate having this opportunity to set out briefly the Government's commitment to providing the highest quality of prevention and treatment.
We are, I hasten to say, neither complacent about nor ignorant of the very real threat that the disease poses to public health and to individual women. No Government could underestimate the seriousness of a condition that affects so many and results in so much suffering and so many deaths each year. My hon. Friend the Member for Colchester, North (Mr. Jenkin) mentioned the wider problem of the damage unwittingly done through the use of excessive radiation in treatment. I assure him that there are initiatives to minimise the risk of any further slip in quality assurance and plans are in hand to ensure that all radiation units are subject to the strictest guidelines so that the unnecessary and disastrous damage to which he referred cannot occur in the future.
It has been pointed out that we have made breast cancer a central element in "The Health of the Nation". Our goal is to cut the number of deaths among women invited for screening by 25 per cent. by the end of the decade. However, it is a tragic fact that breast cancer is still on the increase in this country and abroad. We do not know precisely why that is so, but several social, environmental and genetic factors are at play. Apart from age, factors 954 that appear to increase the risk of breast cancer include late childbearing, the early onset of the menopause, obesity and ionising radiation. They may also include diet, the prolonged use of hormone replacement therapy and a number of other elements into which further research is needed. Given that background, let me summarise what the Government are doing.
It goes without saying that there is a wide network of cancer treatment facilities around the country although, of course, I can necessarily speak in detail only of those in England. However, 7 per cent. of all national health service expenditure goes on the treatment of cancer. Many new units and facilities are being created, and I mention in particular the soon-to-be-opened breast care clinic at Bromley hospital in the constituency of my hon. Friend the Member for Beckenham (Mr. Merchant), which is typical of the new facilities coming on stream.
We have established a national population-based breast screening programme for all women aged between 50 and 64 in support of which new guidelines have been issued to ensure that screening is as effective as possible. We have provided significant funding for research which is supported by, but in no way dependent on, considerable help from major cancer charities. We have also funded the promotion of health material to increase awareness and to encourage women to come forward for screening and to report symptoms.
In the short time remaining, I shall take up the references to the steps taken in the United States. Mention has been made of the apparent switch in spending from defence to health in America. There is no doubt that the defence budget, like many budgets, is stable or dropping while the health budget in this country continues to increase considerably. There has been a 4.4 per cent. increase to all the regions this year, which is well ahead of inflation. I have no doubt that there will continue to be an increase in the share of public spending going on health. A substantial proportion of that will be spent on new cancer facilities because, as has been mentioned, there is too much inequality in provision around the country for the diagnosis and treatment of cancer.
It is well known that too many cancer sufferers, especially women with breast cancer, are not diagnosed swiftly enough. They are not seen sufficiently quickly by people with the appropriate level of expertise, which means that treatment can be delayed. Whatever the clinical effect of waiting for diagnosis and then waiting for treatment may be—it can be serious—the emotional effect is clearly considerable and we need to take action.
Hon. Members have mentioned the chief medical officer's expert advisory group's report. It is a very important document that will change the way in which we examine cancer and its treatment. The fundamental idea is that we must be clear about the different levels of expertise needed in diagnosing cancer. General practitioners need to be absolutely certain how and where to refer patients. If patients are or might be suffering from rare cancers, it may not be appropriate to make a final diagnosis or offer treatment in district hospitals, so there need to be three levels of involvement: the GP, the district hospital and a cancer centre—at least one in each region but perhaps more than one in some—where the most difficult and rare cancers can be treated. There is no point in sending cancer patients to see consultants or doctors who seldom see rare cancers. The expert advisory group's report will ensure the proper referral of cancer patients 955 and that the proper resources are invested to ensure that the appropriate specialty is available for every cancer patient.
Again, I congratulate the hon. Member for Leith on his eloquent speech on what I regard as the most serious problem that faces the health service.