§ Motion made, and Question proposed, That this House do now adjourn.—[Mr. Betts.]
10.29 pm§ Mr. Deputy Speaker (Mr. Michael Lord)Order. I ask hon. Members who are leaving the Chamber to do so quickly and quietly.
§ Mr. StinchcombeThank you, Mr. Deputy Speaker. I am glad to have this opportunity to raise the important subject of breast cancer screening, especially because this is Age Concern's week against age discrimination. Breast screening is one area of health policy in which discrimination against older patients is currently systemic, as I shall shortly demonstrate.
The Government have committed themselves to placing the diagnosis and treatment of breast cancer high on their list of health care priorities. That commitment was amply demonstrated by the £10 million that was allocated in September to improve the symptomatic breast cancer service. The commitment will deliver the real improvement in health care that we seek only if we act on the best available evidence. I sought this debate to bring that evidence before the House and to raise with the Minister two important areas in which much can and should be done to improve breast screening. Those areas are two-view mammography, otherwise known as two-view screening, and the upper age limit for automatic invitations to the breast screening programme.
I make it clear that those two areas are not the only ones that should concern us as we seek to improve breast screening services. There are other related, important areas that must be addressed. They include worrying regional variations in the screening programme and the equally worrying take-up of screening opportunities by those in lower income and ethnic minority groups. There is also the acknowledged shortage of radiologists, oncologists and breast surgeons. Those are all areas for potential reform. However, for two reasons, I have decided to focus on the areas that I have specified.
First, the time is apt, in this week of all weeks, to highlight any area of health care policy that discriminates against the elderly. Secondly, my research leads me to believe that changes to screening policy in those two areas would have the most significant effect on reducing breast cancer mortality, which is currently 14,000 a year—among the highest rates in the world.
Before I deal in detail with the two principal areas upon which I wish to focus, it will help to set the factual context. About 80 per cent. of breast cancers in this country are discovered by women themselves. Approximately 35,000 breast cancers are diagnosed each year but only 6,000 to 7,000 are picked up by the screening programme. Three conclusions can be drawn from that startling fact. The first is that the health education programme in this area has been extremely successful, and that is a cause for some congratulation. Secondly, we should not be complacent. The programme must be extended and improved, especially for older women who, as I shall shortly show, are often oblivious to the fact that they are in the highest risk age category. 952 Thirdly and most importantly, the facts show that the existing screening programme is not being used to its full potential.
Of course funding for research into new and better drugs is essential, and the £10 million that has been allocated to symptomatic breast cancer services is warmly welcomed, but ultimately, the success of those measures will be limited if more small cancers are not detected. Successful treatment of cancers depends upon successfully detecting them in the early stage. We must ask ourselves a simple question: "Can we save more lives by altering existing policies and practice to detect more small cancers?" The answer is yes, we can bring about improvements and detect more small cancers and save more lives. We can do that by expanding two-view screening and abolishing the current upper age limit for automatic invitation to the screening programme.
In 1995, a directive was sent to health authorities requiring two-view mammography to be used for all first-round screens. Why? Because two-view screening detected more small cancers—the very cancers that must be detected if lives are to be saved. However, the improved detection of two-view screening is true not only of first-round screens but of each round of screening. That fact requires no more research or pilot study for it to be established, because the evidence already exists. The evidence shows us not only that two-view mammography detects 45 per cent. more cancers at the first-round screens, but also that it detects at least 25 per cent. more small cancers at incident rounds. Those figures cannot be ignored. They have to be acted upon, especially when one reviews the record of breast cancer screening across the country.
Our target is a standardised detection ratio of one. If we reach that, we will achieve the mortality rate reduction that we seek. If the SDR is under one, we will be under-performing. Whereas the SDR for first-round screens exceeds one, the ratio for incident rounds is lower—between 0.75 and 0.85. That difference can best be explained by the fact that we have two-view screening for first-round screens but not for incident-round screens.
So it is that, under current policy, only one in 10 health regions are meeting the national expected standards for incident-round detection ratios; so it is that many breast units fail even to meet minimum standards; and so it is that, each year, an estimated 450 women with small detectable cancers are given false reassurance, because single-view screens in incident rounds have failed to detect existing cancers. Those figures are deeply unimpressive, especially when the professionals already know how to improve them—by expanding two-view screening into incident rounds.
We know that there will be financial implications, but we must consider two points. First, research shows that, despite the higher overall costs of two-view screening compared to one view, the average cost of screening per cancer detected is similar, so that two-view screening is as cost-effective as one view. Secondly, there is every indication that we will not meet our targets if we do not expand two-view screening.
It follows that, if the targets are to serve any useful role, my hon. Friend the Minister must be able to answer some questions. Has research been done to confirm the number of additional small cancers that would be detected, and lives saved, by introducing that change into 953 screening policy? Do the Government have plans for their own cost-effectiveness study of compulsory two-view screening at all rounds of breast screening? Are the Government in a position properly to assess the relative costs and benefits of the earlier detection and treatment of small cancers that will be achieved by two-view screening at all screening rounds? To what extent, and on what basis, will the Government provide the resources and establish new national guidelines to meet the targets that have been set?
Only when my hon. Friend the Minister can answer those questions will we have a solid basis on which policy on the matter can develop consistently and coherently—not incrementally or in a piecemeal manner—so that we develop a truly national breast-screening programme built on a fair distribution of resources, working to identical standards everywhere and using best shared practice: which means two-view screening at all screening rounds.
The second matter that I should like to deal with is the current age limit for automatic invitations to screening. The target set in "The Health of the Nation" for breast cancer was to reduce by the year 2000 the rate of breast cancer deaths among women invited for screening by at least 25 per cent. That is a tough and a commendable goal. However, as a principle, as a guiding policy, it is both inadequate and discriminatory, because it excludes those women over 65 who are not invited to the screening programme. It excludes those women although in 1992, 63 per cent. of breast cancer deaths were in women over 65. It excludes them when half all new incidences of breast cancer each year are among women aged 65 and over. Not only are we failing to do all we can to detect small cancers in those whom we invite into the screening programme, we do not even automatically issue invitations to older women who are most at risk.
The failure to issue invitations to older women has obvious consequences. Only about 3 per cent. of older women are screened on request during the three-year programme. Something must be done about that. Too often it has been claimed that no decision can be reached until the British pilot studies are completed, but the studies were designed to assess only the practical and logistical implications of extending the screening programme to older women and not the effect on mortality rates of doing so.
We already have evidence on mortality rates. The Two Counties study from Sweden demonstrates that the overall reduction in breast cancer mortality for the 50 to 74 age group was 40 per cent. That is the very study upon which our standardised detection ratios are based. So we know that delay will cost lives.
Too often also it has been claimed that invitations should not go out to older women because there might be a low response rate. The Swedish study refutes that. It finds an uptake of around 80 per cent. in the first round of screening for women aged up to 74.
More importantly, however, what are the ethical implications of that argument? There is evidence to suggest that women from ethnic minorities in the 50 to 64 age group also have a low response rate to invitations. A study has shown the same to be true for women in inner north London. No one would argue that women 954 from ethnic minorities or from inner-city areas should be denied invitations to participate in the screening programme.
§ Ms Julia Drown (South Swindon)I thank my hon. Friend for giving way and for raising these concerns. Is he aware that Swedish research shows that if younger women aged 39 to 49 are invited for screening, the death rate in that age group can also be reduced? Does he agree that when the new institute for clinical effectiveness is launched, it should be asked to find out whether we should use that Swedish research and invite younger women for screening? I should like that to happen so that my constituents know that they can have the most effective assessment and treatment.
§ Mr. StinchcombeI thank my hon. Friend for that helpful intervention. Yet again, she reveals her expertise in these matters. I am aware of the Swedish research and I understand that it found a 13 per cent. reduction in mortality rates in the 40 to 49 age group and that further research will be carried out. The research suggests that invitations to women in that age group will bring benefits, so we should promote that.
We should not discriminate against older women or younger women. Invitations are a vital means of informing women of the risks and of their rights. Invitations should not be channelled just to parts of the population, but made available to all women for whom screening has been shown to be effective.
There is, however, a special reason to send invitations to older women. Not only are they the group most susceptible to breast cancer, but they appear to be the least knowledgeable of the risks they face and the screening to which they are entitled.
A recent Age Concern survey of 1,000 women aged 65 and over revealed that 28 per cent. of respondents believed that there was no risk of their getting breast cancer, when in fact they were in the highest-risk category. Only 30 per cent. thought that their age group was eligible for screening on request. The low take-up of older women for screening confirms that research.
The figures make absolutely no case for denying older women screening invitations that could and would save lives, but they make a compelling case for taking steps better to inform them of the risks of breast cancer and their right to be screened to meet that risk.
We should abolish the existing upper age limit for invitations and launch a targeted programme to educate older women, and similar programmes targeted at ethnic minority groups and lower income groups. The programmes should form part of a coherent strategy that involves GPs, social services and voluntary organisations and that is neither ad hoc nor partial, but carefully devised and implemented on a universal basis, albeit flexibly. It will have to be flexible, because there will be difficulties to address as to how to make the screening programme more accessible to older women without undermining its efficiency. The on-going pilot studies will help to guide us through those difficulties.
However, we cannot wait for those studies before we signal our intentions and act on them. How can we wait when the current system sanctions and reinforces inequality in health care? How can we wait when it discriminates against older women—some of the most 955 vulnerable of our citizens? How can we wait when waiting costs lives—some estimate as many as 2,000 every year? There could be up to 6,000 preventable deaths while the practical implications of the pilot studies are being assessed.
In the light of those figures, serious ethical questions would be raised by any decision not to change the existing discriminatory policy. Some may say that we cannot afford the change. With 6,000 lives at stake, I hope that the Minister agrees that we cannot afford to wait.
§ The Minister for Public Health (Ms Tessa Jowell)I am grateful to my hon. Friend the Member for Wellingborough (Mr. Stinchcombe) for raising this important subject, which he has pursued several times through parliamentary questions and other means. He has given me the chance to stress once again the Government's commitment to improving cancer services. I should like to underline in particular our determination to ensure improvements in the screening programmes for breast and cervical cancer.
We set out that commitment in our most recent White Paper, "The New NHS". One of the three milestones symbolising our new approach to the national health service was the pledge:
we will improve prompt access to specialist services so that everyone with suspected cancer will be able to see a specialist within two weeks of their GP deciding they need to be seen urgently, and requesting an appointment. The Government will guarantee the maximum two week waiting period for everyone with suspected breast cancer by April 1999 and for all other cases of suspected cancer by 2000.Breast cancer is the most common cancer in women. Early detection plays a vital role in maximising the chances of successful treatment. That is why the Government's pledge to ensure high-quality, speedy treatment will bring comfort to millions of women.The breast screening programme is saving women's lives. Last year, more than 1 million women had a mammogram. More than 6,500 cancers were detected. Since the breast screening programme was introduced in 1988, mortality from breast cancer has been falling faster than the European average.
We are well aware that we must not be complacent. We are undertaking a range of initiatives to bring about further improvements in breast cancer services. We are exploring ways in which the breast screening programme might be extended so that women can be offered an even better service. In addition, within a few weeks of taking office we made available an extra £10 million for breast cancer treatment to help to speed up access to diagnosis and to reduce waiting times for treatment by a specialist breast cancer team. That will maximise the benefits of early detection through screening.
The United Kingdom was the first country in the European Community—and one of the first in the world—to introduce a nationwide breast screening programme based on computerised call and recall. As my hon. Friend has made clear, all women between 50 and 64 are invited to be screened by mammography every three years, with screening for older women available three-yearly on request.
956 Evidence available when the breast screening programme was set up suggested that older women would not accept screening invitations. That is why they were not included in the routine call and recall programme. However, screening every three years is available on request to women over the age of 64. Indeed, the availability and importance of screening for older women is widely publicised.
In the light of the references of my hon. Friend the Member for Wellingborough to Age Concern, I am glad to underline that the NHS breast screening programme is working with Age Concern to encourage older women to request screening and to be breast aware. It has produced a leaflet, "65 or over: You are still entitled to breast screening", which is widely available. I was very pleased to hear that the number of women aged over 64 requesting an NHS mammogram has risen from 39,000 two years ago to more than 57,000 last year. It is clearly important that we get the message out to older women to encourage them to make use of this important service.
I turn to the important challenge issued by my hon. Friend the Member for Wellingborough to open automatic recall screening to women over the age of 65. The Government are funding pilot schemes in Brighton, Nottingham and Leeds to evaluate the effectiveness of extending routine screening to women aged between 65 and 69. One of those pilot studies will be completed next year, and the others by 2000. The studies should give a clear picture of the likely uptake among older women and, most important, the effectiveness in terms of the number of cancers detected. We will base any changes to policy on the evidence emerging from the studies. I reassure my hon. Friend of the Government's absolute determination to save women's lives, and to save women's lives by making available high-quality treatment based on the very best evidence of what is effective.
In addition to the pilot studies, other research is under way to look at other changes that might be made to the breast screening programme to improve the service offered to women. In the light of clear evidence that taking two mammographic views of the breast detected 24 per cent. more invasive cancers than a single mammogram view at a woman's first screen—a point made by my hon. Friend the Member for Wellingborough—all breast screening units are now required to use two-view mammography at a woman's first screen. A further study is being carried out to assess the benefits of two-view mammography at each screening round. My hon. Friend asked whether there were plans to look at the cost-effectiveness of two-view mammography at all screens, and if so, how many more cancers we could expect to be picked up. The study under way should provide the answers to those questions.
Research has also been carried out into the effectiveness of reducing the interval between screens. In response to the question of my hon. Friend the Member for South Swindon (Ms Drown) about screening for younger women, I should say that our research extends to an assessment of the effectiveness of screening women under the age of 50.
§ Mr. Paul Flynn (Newport, West)The Minister knows, as do we all, of our atrocious record compared with many other developed countries. The chance of survival is 957 20 per cent. less than in similar countries. Must women wait until 2000 before our own pilot scheme proves what has already been proven elsewhere?
§ Ms JowellAs I made clear, our intention is to assess very carefully in the light of the evidence the improved effectiveness of automatic recall for older women.
It is completely consistent with our priority of improving cancer treatment and saving lives through early intervention and high-quality treatment that we should examine the results of the pilots. If it appears that women's lives will be saved, that will inform our policy.
My hon. Friend the Member for Wellingborough briefly mentioned the acceptance of screening invitations by women from ethnic minorities. Ensuring the proper take-up of screening by women from ethnic minorities is of considerable concern to the Government, because it is through extending access to and use of those services that we will meet one of our key health objectives: to tackle health inequalities.
We are keen to encourage more women from ethnic minorities to be screened. Purposeful action is needed to ensure that that happens. A great deal of action is being taken. We need to work with ethnic communities, through the preparation of information material, such as multilingual leaflets, videos and audio cassettes, and through community-based initiatives. Only through such purposeful action can we increase uptake.
The incidents at Exeter had a devastating impact on the confidence of women who relied on the service. We have taken action to put right what went wrong and to ensure that, as far as is humanly possible, similar mistakes cannot occur elsewhere.
The report into the breast screening programme at Exeter, published last November, concluded that there had been a failure to diagnose a number of cancers and to refer women for appropriate treatment. Major factors identified included the lack of a proper accountability framework and of proper responsibility for quality assurance.
The Government acted quickly to rectify the shortcomings. In November, we announced an overhaul of breast screening to strengthen quality assurance; to 958 eliminate weaknesses in the organisation and management of screening; and to restore public confidence. The measures to make the quality assurance system more robust are especially important, because, if they go wrong, the consequences for women can be catastrophic.
§ Mr. StinchcombeI am glad to hear that we responded rapidly after the events at Exeter, but we do not need to wait for further pilot studies on two-view mammography or on the upper age limit, because we know what will happen: lives will be lost. Why do we not anticipate events, rather than reacting to them?
§ Ms JowellResearch is already under way to establish the effectiveness of those measures, especially in relation to recall and the opportunity for older women to be screened. We are working with Age Concern to encourage that. When the NHS White Paper was published, we made it clear that improving quality and national consistency would be the hallmark of building a modern, dependable national health service. Those principles apply equally to breast screening services and to treatment services that women may need subsequently.
The Government signalled their intention to improve cancer services and, since coming to power, made available as a first step £10 million for improvements in breast cancer services. That money is being used to support more than 300 initiatives to improve the diagnosis and treatment of breast cancer throughout the country, building on the vital work of the breast screening programme, which is so important for the serenity and peace of mind of women and their families.
Those are the steps that we are taking. I assure my hon. Friend and the House that we will continue our work to provide breast cancer services of the very highest quality. We are determined to ensure that we save more lives by applying the evidence of what works in practice.
§ The motion having been made after Ten o'clock, and the debate having continued for half an hour, MR. DEPUTY SPEAKER adjourned the House without Question put, pursuant to the Standing Order.
§ Adjourned at one minute to Eleven o'clock.