Breast Cancer

HL Deb 26 May 1994 vol 555 cc912-42

3 p.m.

Lord Ironside rose to ask Her Majesty's Government in what ways they expect to improve diagnosis and surgical treatment of breast cancer and to avoid hazardous radiotherapy treatment of this condition.

The noble Lord said: My Lords, I am very glad to have this opportunity of drawing parliamentary attention to a subject which is causing widespread public concern—concern which has been building up for six months or more now. It has caught the attention of the press, television and radio from different angles, all of which I believe have been fairly and accurately represented, without their dramatically overstepping the mark.

If there was a moment that triggered off this issue, I think it was the public meeting that was held by RAGE (Radiotherapy Action Group Exposure) at the London School of Economics on 4th September 1993. The meeting was brought about by the enraged feelings of thousands of women who suddenly discovered for the first time that their brachial plexus injuries—that is to say, the injuries to the network of nerves, blood vessels and lymph glands in the upper arm and front of the shoulder around the collar bone —such as unremitting and irreversible pain and arm paralysis—were a direct result of the radiotherapy treatment that had been prescribed as a precautionary measure following breast cancer surgery. Yet they had been told that the treatment would involve no greater side-effects than temporary nausea and discomfort.

I follow the good example of my noble friend Lady Cumberlege and draw on the dictionary for the definition of "side-effect". It refers to: "an unwanted but subsidiary effect". I believe the House will agree with me that paralysis and unremitting pain go far beyond the phraseology of "side-effect", about which we so often hear from practitioners, often as a euphemism for something worse, to sooth the patient. One can understand why the members of RAGE are, to put it bluntly, so enraged by being misled.

There are some 1,029 members of RAGE in England who are the known victims of radiotherapy treatment and countless unknown others who are either too afraid or too embarrassed to come forward, or have never thought of doing so, and there are those from Scotland who have contacted RAGE numbering some hundreds —I believe probably over 400. I shall say more about that later. But those who are still alive are probably alive in spite of the treatment.

Noble Lords will wonder why I raise this Question. I have been closely involved with the issues as my wife is president of RAGE, and I declare an interest— particularly as compensation is on the RAGE agenda —to seek amends for the very large number of innocent victims of horrific injuries. The question of compensa-tion arises as so very few of them—in fact, those whose incomes are low enough to qualify for legal aid—can afford to take legal action. This is an aspect of the issue which RAGE wants the Government to consider. I am very grateful to those noble Lords who are taking part in this debate and for their willingness to address many of the implications of my Question: for example, consequential injuries such as fibrosis, heart damage, brittle bones, lymphoedema (that is the swelling of the arm) and even amputation.

I would like to say how grateful I am to my noble friend on the Front Bench, as the Minister with responsibility for breast cancer matters, for the serious attention that she has given to this issue and for holding a meeting with RAGE, as well as for arranging subsequent discussions for RAGE and others to examine with the Chief Medical Officer the way forward. I assure her that she has the full co-operation of RAGE, which has the basic information of when and where its members were treated, in the absence of central government records being available. That has been done without divulging names.

While victims are afraid of being critical in front of those from whom they still have to seek treatment, they are prepared to confide in RAGE in the knowledge that their collective voice will be heard. What has come to light is horrific. Thousands of women have had their lives shattered, not by cancer but by radiotherapy treatment, about which they had absolutely no warning —they had no warning at all of the serious consequences—after having it prescribed as a precau-tionary measure or a mopping up process, as in my wife's case. She has given me permission to tell the House that two years later, when her injuries became apparent, she was informed, too late, that for administrative reasons, to increase patient through-put, treatment had been given not in doses every day but every other two and three days in alternate weeks for six weeks. That meant higher doses for each fraction and the nerves cannot take that kind of bombardment— which was known from many professional papers at the time. Dreadful complications have thus occurred, after being totally misled about the consequences and having put trust in the practitioner.

However, that is not, as noble Lords might expect, a part of history. The frightening thing is that injuries are still occurring at radiotherapy treatment centres. My wife had textbook screening, early detection and expert private surgery. But all for what? To be crippled for life by RT treatment designed to put a lethal finishing touch to the surgeon's knife, as a precaution.

The pattern of treatment in the UK varies from centre to centre and different regimes are operated according to guidelines—we are told, very strict guidelines. I shall corne back to that point later. RAGE has supplied a list of 525 members showing the incidence of brachialplexus injury at radiotherapy treatment centres with dates going back some years. Of the 53 centres in the United Kingdom, there were 12 with 10 or more injury cases, five with 20 or more cases and one with 59 cases. The remainder had fewer than 10 and many much fewer. If an all-embracing analysis of complete data was earned out, and not just those data from the RAGE membership, the likelihood is that the same injury pattern would manifest itself.

The question that has to be asked, therefore, is why that disproportionate effect apparently exists in the United Kingdom and why the radiotherapy treatment is apparently such a lottery. Incidentally, much the same thing is said about breast cancer surgery. My noble friend on the Front Bench has said that it is important to investigate now, even though the data are not complete —and I agree with her—to find out what has happened, where it happened and why it happened; and to prevent it happening again.

I can assure my noble friend that I am closely involved in following this matter through, at her suggestion, with those professionals most involved, so that, as agreed with the Chief Medical Officer, an audit can openly take place. It is not a matter that can be brushed under the carpet.

I return to the question of guidelines. As I said, we have been told by Ministers that the National Health Service operates strict guidelines on RT treatment. But that does not go far enough. These days we hear a lot about guidelines and that magic word sounds good. But guidelines do not necessarily ensure that things go the right way. Quality assurance to a national standard is needed in radiotherapy treatment, as guidelines are not compulsory and can be interpreted in different ways by different people. In fact, I would say that there is a crying need for quality assurance in RT treatment. I am glad to see that the Expert Advisory Group on Cancer in my noble friend's department has made that recommendation in the consultative framework docu-ment which has just been published. I congratulate her on the publication, which goes to the heart of the matter, and which I hope will now put everything right.

Reading the detailed working party report on quality assurance in radiotherapy, which draws on the practices at the Bristol oncology unit and the Manchester Christie Hospital, I am glad to see that quality assurance in radiotherapy is to be looked at on a national basis in line with the British National Standard BS 5750. Like the MOT test certificate for vehicles, approval to the standard will have to be renewed at regular intervals. It is suggested that that should be every six months. If that is to be the plan, then firms making the assessment must, if the certificate is to be worth anything in the eyes of patients, be accredited by the DTI as having the expertise needed to make the assessment in this radiotherapy field. On the other hand, there may be arrangements for that to be done in-house by the Department of Health as the Ministry of Defence used to do some years ago, though it is now put out to contract. However, I note in the quality assurance manual—I do not know its status but it is a fairly detailed document and I do not know whether it is temporarily in force or what—under paragraph 3.10 on page 8 it says: Formal certification of a system against BS 5750 will require regular external audit by an assessment body whose accreditation covers radiotherapy organisations. At present (April 1994) no such body has such experience and auditing can only be offered by companies specialising in professional organisations". One can see from that that a lot of work needs to be done to find firms capable of making assessments.

I will go on to say that screening, diagnosis, surgery and all therapeutic treatments need to be thoroughly integrated so that the habit of passing the parcel—or in this case passing the patient—from one doctor to another can be regulated. The habit of passing the parcel in medicine in any case calls out for quality assurance to a national standard. I recall, after my recent Question to the House in relation to quality assurance in radiotherapy, that I was approached by the British Medical Association. I was asked what my worries were. I said that I was expressing public concern over the need for QA to BS 5750. The BMA said, "What is BS 5750?" I hope it now knows. If it does not, it should read the report and manual on QA in radiotherapy.

Finally, we must not forget that there is a Scottish element to be reckoned with. If breast cancer is a UK issue, then I am concerned that the pace and direction of efforts in Scotland—and Northern Ireland for that matter—may conflict with that in England and Wales. I hope that my noble friend can ensure that there will not be a North-South divide between the Expert Advisory Group on Cancer and the Scottish Cancer Consultative and Advisory Committee. Perhaps I begin to detect a hint of Scottish cancer being present and a different problem. I hope not.

There is grave public concern about all aspects of breast cancer and there are now references almost daily in the papers or on television about it. I hope my noble friend can give specific assurances that she intends to resolve the issue related to the injuries in radiotherapy treatment and get results. I am well aware that clinical opinion is always regarded as paramount and every patient is different. But so is every doctor. To my mind, and I hope to the Government's mind also, that justifies the necessity for practice to be tempered with quality assurance. There may be resistance to quality assurance in professional medical circles. But the MoD, as a customer, calls for it and other public sector bodies, as customers, are also calling for it. I hope that every woman will call for it before she goes into a radiotherapy treatment centre as it must help towards providing the right solution and reducing the risk factor to where it should be; ideally zero.

3.15 p.m.

Lord Molloy

My Lords, I am sure that the whole House and the many medical organisations in our country will be most grateful to the noble Lord, Lord Ironside, not only for introducing the debate, but also for the manner in which he did so, covering almost every aspect. I made a little study myself and I have been reading the endeavours of probably the biggest organisation in Europe, the trade union UNISON. It did a thorough search on this matter. When I was listening to the noble Lord I thought I was hearing the words of UNISON all over again. The union, in conjunction with other organisations, conducted a thorough examination of the situation.

For example, in this morning's Nursing Times, one of the major articles is, "Cancer: a special case". It goes on to cover not only the points made by the noble Lord but many others as well. If I can say so, speaking parenthetically, they have full confidence in the Minister here today to take part in future discussions as she has done in the past. The endeavours of the Minister therefore should also be placed on record.

One of the points that seems to be disturbing people is the fact that many district hospitals are substandard and do not seem to know a great deal about all the treatments required for anyone suffering from this appalling disease, breast cancer. Another aspect is that consultants see too few cases to be able to specialise later on in trying to find a rapid cure for the disease. Proposals to reorganise put forward by the advisory group chaired by Sir Kenneth Caiman are urging the department to iron out the inequalities of care around the country. The group is of the opinion that there is a strong case for an independent inquiry into the use of radiotherapy. Other medical organisations join the advisory group in that plea.

Any possibility of breast cancer should mean prompt referral to a specialist team of a surgeon oncologist and a radiotherapist with access to specialist breast care nurses. That is sometimes not happening, probably because people just do not know what to do. GPs should be informed exactly what they have to recommend. That is another vital aspect that we would like the department to look at.

Breast cancer kills 300 women a week. I did not believe the figures and so I made certain. I was shattered when I was given detailed information about what it means not only to die from breast cancer but to suffer in the period when you are dying from breast cancer. No civilised nation would allow this to go on. Unfortunately, my country has one of the world's worst death rates. The disease affects one woman in 12 and therefore there is a special need to have screening immediately there is any danger of cancer.

There is an urgent need to train specialist doctors, specialist surgeons and specialist nurses but that is not enough without distinct and specialised research from which the specialist doctors, surgeons and nurses can learn. A massive endeavour is required to prevent or cure this disease, with more research required either ultimately to cure or to prevent in the early stages women suffering from breast cancer.

Breast cancer is most evil and frightful. When the children of a mother with breast cancer discover that she has that disease, the entire home is affected. That is how serious I believe the subject to be and we must take cognisance of it. I believe that in our country we have the ability and resources to provide more cancer specialists, doctors and nurses. I hope that the noble Baroness will look into this plea, which comes from many distinguished breast cancer specialists as well as from the organisations with which they work. They feel that there should now be a special national conference involving specialist breast cancer doctors, surgeons and —very important—specialist breast cancer treatment nurses. There should even be specialist hospitals to control and ultimately defeat this terror.

There is an urgent need for more specialist nurses for the operation, not only at the time when it is carried out, but also to return home with the patient to help out. That is a vital aspect of the work. There are not enough specialist cancer nurses. Let us hope that something can be done. I am sure that the noble Baroness has read the reaction of RAGE (Radio Action Group Exposure), which make some very valid and telling points. They are experts in what is required and what needs to be done.

In conclusion, our National Health Ministers have the desire and the ability to tackle this problem. I am convinced that our Ministers in this House and in another place, when they come to grapple with the problem, will make a massive contribution which will be looked on as something wonderful by all families where a mother or a relative has breast cancer. Therefore, I believe that the Ministers concerned with our National Health Service deserve the full support of us all to bring about many of the improvements which the noble Lord, Lord Ironside, has called for and the few suggestions which I have submitted in his support. Thank you.

3.23 p.m.

The Countess of Mar

My Lords, the noble Lord, Lord Ironside, has tabled this Question at a particularly appropriate time for me, and I am very grateful to him for asking it. Three-and-a-half years' ago my closest friend found a lump in her left breast. Very soon after her discovery she had a mastectomy and was given a single dose of radiotherapy as a precautionary measure which lasted 11 minutes. She was also given tamoxifen. She subsequently, at different times, developed secondary tumours in her skull, ribs and liver. On each occasion she was subjected to a single dose of radiotherapy for several minutes.

Towards the end of last year she began to feel sensations of pain and numbness in the first two fingers of her left hand. This was reported to her consultant who offered no explanation, advice or prognosis. Since then I have watched the muscles melt from her arm. I have seen her in excruciating pain as her digits turn into the palm of her hand in spasm, and, worst of all, I have seen her distress at the lack of an explanation for her suffering. It was not until this Monday, when I read the article by Lady Ironside entitled "The Safeguard Killing Patients" in a parliamentary brief of October 1993, that all the pieces of the jigsaw fell into place. I am profoundly disturbed that in 1994 a consultant radiologist should fail to fully inform his patient of the hazards, known for 30 years, of the treatment he is going to give her and that he should fail to give her an explanation when a known side effect manifests itself. It may be that the consultant, knowing that she was a nursing sister, believed that she would know the possibilities, but surely it was incumbent upon him to make sure.

My friend's case almost parallels that of Lady Ironside. She was today to ask her consultant about the possibility of having a sympathectomy or a nerve block to eliminate the pain in her arm. Armed with a copy of Lady Ironside's article, she will now be able to approach the subject with more understanding and without the unquestioning acceptance of the consultant's opinion so ingrained in her by her training.

It is too late for my friend. It is not too late for other women who may discover that they have breast cancer in the future. It is shock enough for a woman to learn that she may have to lose a breast. At least her public image can be retained if she is properly counselled and has a good prosthesis. The loss of the use of an arm, or even the arm itself, is even more distressing as she loses with it a great deal of independence. To discover that she is not a unique case may be a small consolation, but what a poor reflection it is upon members of the medical profession who are responsible for the treatment of women with breast cancer.

I have read with great interest the consultative document, A Policy Framework for Commissioning Cancer Services, prepared by the Expert Advisory Group on Cancer to the Chief Medical Officers of England and Wales. I have also read about the Scottish Cancer Therapy Network. I am delighted to see. that the Scots have taken the initiative. Since the 1992 policy statement Scotland's Health, a network has been established and preliminary action on six out of eight site-specific cancers has been taken, with cancer of the breast and colon being given priority.

May I ask the Minister why it has taken the English and Welsh Chief Medical Officers so long to get around to solving the problem of the inconsistency of treatment and outcome for cancer patients when it has been known for many years that the prognosis has differed according to the treatment centre? It would appear from the consultative document that the advisory group does not expect quick results. I urge the Minister to use her influence to impress upon all those responsible for both primary and secondary care of women with breast cancer to note particularly paragraph 3.6 of the consultative document, entitled "The Relationship of Cancer Services with a Primary Health Care Team"—I am tempted to add, "and with the patient".

I am aware that there are some excellent cancer centres where the patient is totally involved and fully informed at every stage of her treatment, with information provided according to the patient's level of comprehension. I know a number of cancer patients and their relatives who have received a tremendous amount of support from Cancer Relief Macmillan Nurses and I cannot sing those nurses' praises too highly. They have among their assets that very important ingredient: time for their patients. If each woman who has had breast cancer diagnosed was allocated a specialist nurse who could explain procedures to her and provide support for as long as she needs it, many of the psychological effects of the disease would be ameliorated.

Diagnosis of breast cancer is no longer the death knell it once was. Many women survive to live long and fruitful lives. I can see no logical reason why the lessons learned about the survivors should not have been accepted by those consultants, whether they be surgeons, physicians or radiologists, who have proved to be less successful in their management of the disease.

The incidence of breast cancer is known to be increasing and, until the cause or causes can be pinpointed and preventive measures taken, there is a need to ensure that all women receive the treatment which is currently known to have not only the highest success rate, but subsequently lead to the best quality of life. It is simply not good enough for a women who is left with a useless, painful limb, fragile bones and the fear of other unknown side-effects of radiology to be told, "You are lucky to be alive. What more do you expect?"

3.28 p.m.

Baroness Gardner of Parkes

My Lords, this is a most interesting Unstarred Question and I am grateful to the noble Lord, Lord Ironside, for tabling it. Over half a million women worldwide develop breast cancer every year, but the distribution is not spread evenly throughout the world. Over half of the cases occur in North America and Europe, although those countries contain less than one-fifth of the female population of the world.

Japanese women in Japan have low breast cancer rates, but second and subsequent generations of those who migrate to the US have the same rates as their host population. That would seem to indicate that social and environmental factors, not just genetic factors, are significant. Breast cancer is a disease which occurs mainly in Western developed countries.

As we all know, a woman's chance of survival is increased greatly by early detection. The increase in mortality rates reveals that those in the older age group are helped even more than those in the younger age group by early detection and screening. Some years ago the Forrest Report recommended the introduction of a general screening programme for all 50 to 64 year-olds. At the time I represented the women of the UK on the UN Status of Women Committee. We were concerned that the recommendations of the Forrest Committee might not bé implemented. Women throughout the country wrote to the Prime Minister who then implemented the programme. Screening of women in that age group produces 10 per cent. of women with the disease.

I am privileged to be the new chairman of the Royal Free Hampstead NHS Trust. I should like to share with Members of your Lordships' House some of the latest and best procedures which we are using for all our patients. Before I do that I should like to comment briefly on a point made by the noble Lord, Lord Ironside. Radiotherapy treatment has improved greatly in many hospitals as a result of the use of conformational radiotherapy. The patient is put on a simulator which assesses in a three-dimensional way the exact size, location and density of the lesion. Instead of radiotherapy which is a wide scatter system affecting other tissues, the treatment can be much more localised, and that is a great improvement.

Chemotherapy is often given in pre-operative treatment to reduce the size of tumours before surgery. That is proving to be successful. Different drugs are used according to the age of the patient. Tamoxifen is the common drug for the post-menopausal patient. There are many different varieties of cancer. One of our experts estimates that there is something like 100 different varieties of breast cancer. Under the old system a patient had a mammogram. It was then decided whether something required investigation. The patient was given a general anaesthetic and while under the anaesthetic a biopsy was done to see whether the lesion was malignant. Now a different technique is used. It is fine-needle cytology. Through that, the type of lesion and the type of treatment required can be determined. That is a big advance and saves many women. I have a friend who went through the terrible experience of having an anaesthetic. She was told that the tumour would be benign. The doctors did not obtain her consent to further surgery, and then while she was unconscious they discovered that the tumour was malignant. They had to bring her back to consciousness to obtain her consent to further surgery. That is a terrible trauma for anyone to face twice. Under the new system people would not have to do that.

I shall return to some of the work being done by the Royal Free Hospital. I draw my noble friend the Minister's attention to the fact—this is important—that Dr. Parbhoo, who is the director of the Royal Free Breast Cancer Unit, has been conducting some surveys on older patients in the 10 years after the end of the official screening programme. Of 1,000 patients screened in that age group, over 20 per cent. have been found to have breast cancer, although in the younger age group it was only 10 per cent. Those figures do not relate directly one to the other, because many fewer people in the older group are being seen, and those who come in to be checked are those where there is a suspicion that treatment might be required. Nevertheless, 20 per cent. is a significant figure. The other significant figure is that relating to the survival benefit for all breast cancer patients; it is 26 per cent. better than before the screening programme was introduced. Therefore, screening has had a major impact on survival.

The incidence of the disease does not double in old age. The aim is to reduce deaths from breast cancer by 2,000 a year by the year 2,000. Those figures may sound like a neat pattern but it is the medical target. The disease occurs mainly in women but not solely; 1 per cent. of breast cancers occur in men and it is treated in different ways. The diagnosis of breast cancer can be done by mammogrammes and fine needle aspiration and can be shattering, as was said by the noble Countess, Lady Mar. It is not just the fact that one has a terrible disease; there is also the emotional content. Women feel that to lose a breast is to lose some essential part of themselves and their nature. That is an important point and counselling is valuable in helping patients to understand what they face and to reassure them that they will be in good hands and will receive the most caring and best treatment.

At the Royal Free Hospital we have an established charity called Cancerkin. It was established in 1987 by Mrs. Gloria Freilich in conjunction with Dr. Parbhoo, the breast surgeon. The charity has raised more than £1 million through the breast cancer appeal. On 4th July this year, Cancerkin will move to a special purpose-built centre within the hospital. It will provide a unique service with one of the only dedicated lymphoedema clinics for breast cancer. It will also have a counselling room and an information and resource centre. Lymphoedema was mentioned by the noble Lord, Lord Ironside. The arm of a patient visiting the centre might be four times the size of a normal arm. I did not know what form of treatment was available but I now understand that it is physiotherapy which encourages the flow of the lymph through the arm and increases the movement. It is reasonably effective and it is encouraging for patients to feel that someone is caring and trying to do something about the condition.

The Cancerkin centre will also provide important data for the Royal Free's research programme into the causes, prevention and manipulation of the risk of breast cancer. Work in molecular biology, genetics and molecular endochrinology requires finance and space. The National Health Service will never have enough money for the amount of research that is still to be done to prevent this spread of disease. The Cancerkin centre is playing an important role in providing additional resources for that purpose.

There is limited time today and this is a vast subject. There are three essential requirements for women. The first is access to diagnoses and treatment. The second is a multi-disciplinary team to provide the necessary treatment. The noble Lord, Lord Molloy, touched upon those points. The third is a surgeon—not just a surgeon but one with a special interest in breast cancer. Women should be able to see a specialist surgeon operating on not less then 50 breast cancers a year. Surgical and non-surgical expertise is necessary.

Dr. Alison Jones is our physician oncologist specialising in breast cases. We are fortunate to have such a medical expert because they are in short supply and one cannot create enough to meet the need overnight. There are only 80 experts with that qualification in the United Kingdom. I ask the Minister to assure us that the Government are aware of the need for a planned increase over the next 10 years.

An important team member is the counsellor—a nurse specialist in breast cancer. The multi-disciplinary approach—surgery, radiotherapy and medical oncology —give any woman with breast cancer the best prognosis. In the recent Caiman Report, the Government have recognised that situation and more specialist centres for cancer treatment will be planned. Women will welcome that.

Meanwhile, I say to those women who have cause for concern: ask about what is available and where; ensure that you are referred to a centre which can provide the care that you really need; it is your life.

3.40 p.m.

Lord Ennals

My Lords, as a patient of the Royal Free Hospital, I am delighted to know now who is my new chairman. I assure her that I shall keep her busy with questions, sometimes complaints and sometimes a need for reassurance. But it is good to know that I know who is the chairman of the trust.

I wish to congratulate the noble Lord, Lord Ironside, on raising this issue. The debate has probably proved to be even more topical than he thought it would be when he tabled the Question. His purpose is to draw attention to the seriousness of the issues that we have been debating. He referred in particular to the injuries caused to a large and identifiable group of victims of radiotherapy who were treated in the UK and who are suffering disastrous consequential effects from avoid-able radiation damage.

The pattern of injury has shown that cases are clustered around some but not others of the 53 treatment centres. Some lessons must be learned from that. There is a crying need to find out what happened, where and why it happened and how to prevent it from happening again. Thus a complete investigation is called for. A demanding search through all the links in the chain is needed; namely, from screening and diagnosis through to surgery, radiotherapy and other therapeutic treatments.

The noble Lord, Lord Ironside, is a formidable champion on behalf of his wife and RAGE. I find it interesting that since there was an exchange in the House on this matter I have received many letters from people who were clearly motivated by RAGE. It has become an extremely effective charity. Through the noble Lord, perhaps I may congratulate his wife on her great courage following her own treatment. I shall not describe her treatment as "disastrous" because we come through disasters, but she has earned the respect of many people in this House.

Many of your Lordships will have seen a leading article in The Times on 15th January of this year. That article dealt with a survey of 417 women who had been diagnosed as suffering from breast cancer which was published in the British Medical Journal only a day before that leader was published. It showed that the guidelines for the treatment of the disease were in many cases not being followed. Since the survey was carried out in 1990, some progress had been made. More than 1 million women were being checked each year under the NHS screening programme which offers women aged 50 to 64 an X-ray check-up every three years. Of course, that is very good. More than 6,500 cancers were detected during 1992. But much more should be done. That is the message which the noble Lord, Lord Ironside, has brought to the debate.

Better diagnostic services are needed for younger women. The law still does too little to help a woman with breast cancer whose condition is misdiagnosed through medical negligence. The main area of concern should be an apparent arbitrariness with regard to much of the treatment following diagnosis. In spite of guidelines published in 1986, the manner in which radiotherapy, chemotherapy and other forms of treatment are used is far too variable and diverse.

The British Medical Journal survey showed alarming disparaties in techniques used to treat women of the same age with cancers of similar severity. For example, four out of 10 premenstrual patients in whom the disease had spread did not receive the recommended chemotherapy. Moreover, in only one in four cases was the severity of the cancer correctly assessed. I shall quote now from The Times leader on 15th January which said: In particular, there is a strong case for an independent enquiry into the use of radiotherapy to treat breast cancer". That was the plea made by Lady Ironside in the article to which reference has already been made under the heading "The Safeguard Killing Patients".

I believe that that demand is right. Since then, the Cancer Relief Macmillan Fund to which reference has already been made—indeed, in a congratulatory tone, I think that we already have tremendous admiration for the work done by the Macmillan nurses—has said that women with breast cancer should be promptly referred for specialist treatment. That does not always happen. It is often a belated diagnosis which leads to some of the problems that have been mentioned.

In response to growing public and patient concern, the Department of Health has now announced a new cancer treatment programme. That followed the recommendations of the committee over which the Chief Medical Officer presided. I hope that the Minister will say something about those proposals as they relate to the concerns that have been expressed by many speakers during today's debate.

There are further grounds for fearing that treatment in Britain is often of a poorer standard than in other countries. No doubt the Minister will want to comment on some of the allegations that have been made. Experts have said that Britain lags behind the rest of Europe. Proportional to the population, there are fewer cancer specialists in Britain than, for example, in Poland.

Professor Karol Sikora (who many of us will know is an outstanding expert in the field of oncology) from the Hammersmith Hospital in West London has claimed that some cancer patients would be better treated in the third world. That coming from an expert is a very damning criticism of the quality of treatment in Britain. I hope that the Minister will also comment on that. It is estimated that only one in two patients will see a specialist and that thousands die unnecessarily.

It is worrying when one hears criticism of the quality of treatment by the National Health Service as all of us have so much pride in that service. It is also deeply distressing to hear of so many cases being diagnosed each year, with so many people dying, one may feel, unnecessarily. I hope that the Minister will give a sterling response to the concerns that have been expressed during today's brief exchange.

3.50 p.m.

Lord Colwyn

My Lords, I listened with great interest to the moving way in which my noble friend Lord Ironside initiated the debate. I hope that the experience of his family will contribute towards significant advances in the diagnosis and treatment of this disease which affects one in 12 women and is probably the most important public health factor which women face today.

It seems that any improvements in case survival or mortality rates are being overshadowed by a real increase in the incidence of the disease. It is reported that of the 16,000 deaths each year, 5,000 British patients die because they do not receive the best treatment. The claim that one in 10 of those patients could survive if treated in any other Western European country is a sad reflection on the British record of treatment.

I would welcome the report of the expert advisory group on cancer, A Policy Framework for Commissioning Cancer Services, published on 18th May. I have only just been able to obtain a copy so cannot claim to have read the document fully. But I was sent a copy of the press release by Susan Butler from the Cancer Relief Macmillan Fund office yesterday.

The report, which has been prepared by the Chief Medical Officer, Dr. Kenneth Caiman, for my right honourable friend the Minister does not admit to any failings but implies criticism of Britain's record and notes substantial variations in patient survival in different parts of the country.

I am aware of the survey by the College of Radiologists which it admits produced disturbing results when treatment protocols were compared for similar cancers in different regions. Treatments varied dramatically and there was no evidence of standardisa-tion. I gather that a grant has been made available from the department to do something about the problem.

I hope that the Minister will be able to say that extensive reforms of cancer treatment are likely to be implemented by the end of next year, with the possibility of a network of regional hospitals becoming high-tech specialist centres, each serving a population of not less than 660,000 people. These centres will have the latest diagnostic equipment, specialist surgeons, services for child cancer patients and the latest drug and radiotherapy treatment facilities.

I think that the report implies that the doctors working in the units will be expected to spend at least half their week treating cancer patients so that they can become experts. There are only 342 cancer doctors in Britain and 65 per cent. of patients never see one, some being treated solely by their GP, who cannot be expected to have gained sufficient experience from relatively small numbers of patients.

Like the noble Lord, Lord Ennals, I should like to support the minimum standards of care called for by the Macmillan Fund. I shall not detain your Lordships by repeating them, but they call for prompt diagnosis, referral and access to treatment, with back-up information and psychological support from specialist breast care nurses. The fund stresses the need for accurate information and explanation of the disease, its treatment and associated aftercare.

Speaking to the All-Party Parliamentary Group on Breast Cancer on 22nd March (regrettably I could not be there as the meetings of the group are always scheduled for mid morning when many of us have to work—and that is a public plea for the group to change the time of its meetings) Professor Michael Baum said that the best prospect for the primary prevention of breast cancer is to concentrate on using some form of chemical intervention. I am sure that that is correct for some cases, but as a supporter of natural medicines I feel sure that the answer lies in earlier screening for deficiencies in basic nutrition and hormonal chemistry.

The actual mechanisms by which cancer is caused are still speculative. The genetic theory which proposes that cancer is the product of chromosomal DNA damage induced by radiation, viruses or toxins, which—as the patient gets older—the natural ability to repair is prejudiced is now replaced by the epigenetic theory, which suggests that correcting and maintaining a healthy intracellular environment will prevent cancer and lead to successful non-toxic treatments for the disease.

Both breast and endometrial cancer are health risks which tend to surface in women at a time when oestrogen is dominant and progesterone is low. The cancer protective benefit of progesterone is clearly indicated in a prospective study in which pre-menopausal women with low progesterone levels were found to have over five times the risk of developing pre-menopausal breast cancer and a tenfold increase in deaths for all malignant neoplasms compared with those with normal progesterone levels.

As women approach menopause, breast and endometrial cancer are two of the greatest fears. When the cause of a cancer becomes known, prevention becomes a reality. Lung cancer, for example, can be almost completely prevented by avoiding cigarettes. A great deal is known about the hormonal factors in breast and endometrial cancer. I hope that the new initiative will include trials and tests on the use of progesterone and its opposition to the carcinogenic effects of estrogens.

I thoroughly commend the setting up of a proper programme for the screening of men and women for cancers and heart disease. Risk factors are only rarely considered when it is too late. I hope that the Government will listen carefully during the three-month consultation process. I am grateful to my noble friend for asking the Question and I hope that our debate will perhaps contribute to those consultations.

3.55 p.m.

Earl of Baldwin of Bewdley

My Lords, I, too, welcome the chance to support the noble Lord, Lord Ironside, in putting this crucial question to the Government, which he has done with great clarity and skill. I look forward to hearing the reply of the Minister, although of course we know something of what she will say from the recent reports in the press, about which other noble Lords have spoken: and most welcome they are too.

My interest in the subject is twofold. I have been active for some time in the world of complementary medicine, which has led me to look closely at alternative approaches to cancer, among other conditions, and by extension to keep an eye through the medical press on what is going on in the mainstream. And, like the noble Lord, Lord Ironside, my wife is a breast cancer sufferer, and the last many months have been fraught with difficult decisions about possible lines of treatment.

From the very beginning we learnt that the figures were stark and there was no place here for rose-coloured spectacles. Breast cancer in the UK, as we know, is rampant. Statistics show that only three women in 10 live out a normal lifespan. The treatment options are extremely unattractive. Radiotherapy was urged on us, after an unavoidable mastectomy. We established that it might not be necessary, since no one knew if the cancer would recur; that if it was necessary, there was no guarantee it would work; that if it did work there would be side-effects which, though probably as insignificant as surgeons and oncologists like to claim, could possibly be as devastating as some of the cases we have heard about this afternoon; and finally—this from a major published review of studies of radiation to the chest—that if you have the radiation you will probably die a bit sooner than if you do not. At the end of this I thought, "What kind of medicine is that?"

It was only later that I was able to study the POST report of last month and learn of the extraordinary complexity of the various steps in radiotherapy treatment, with its countless opportunities for error, to say nothing of the lack of consensus about treatment regimes, about which we have already heard. To my mind, my Lords, this is the unacceptable face of aggressive, technological medicine. There must be a better way, and in a moment I shall return to this theme. So far as diagnosis and surgical treatment are concerned, our experience has been of the best: swift, efficient and as painless as anything so awful can be. But I know that this is far from typical, alas, and would join my voice to those who want to see a levelling up and a better organisation of facilities and expertise round the country. As an aside, I must express some scepticism about the merits of screening which have been put forward by one or two speakers, in view of the continuing controversy in the medical press as to whether it actually brings the benefits that lay people like us would think that it ought to bring.

There is another area where from my recent experience there is room for improvement, though it does not only apply to breast cancer. I read last December that the Minister said at a College of Health conference that effectiveness bulletins on the best means of treating different conditions were to be produced in patient-friendly form. In view of the Audit Commission's findings in November on the poor quality of communication from doctors to patients this is to be welcomed, though it is only a part of the picture. It is not at all easy for a patient to discover the facts about her illness and treatment—full, clear, unbiased facts, with figures where needed, and side-effects not glossed over. Breast cancer is a stressful enough experience without having to fight for the information on which to base decisions which are no longer the preserve of the paternal figure behind a consultant's desk. I hope that the medical profession will take this on board with all seriousness.

The question is, in what ways the Government expect to improve the situation. That there is room for improvement is surely common ground. Variations in treatment, as we have heard, go way beyond the bounds of legitimate clinical judgment, and the damage done to patients, even on standard treatment regimes, is or should be unacceptable. We have heard many of the details from the noble Lord, Lord Ironside, and there is no need for me to repeat them. There used to be. a medical maxim: "Above all, do no harm". I wonder what happened to it.

The report of Dr. Calman's committee is to be welcomed, as far as it goes, and I shall say no more about it here. Other noble Lords have spoken eloquently on the subject. But when you stand back and survey the cancer scene over time, a grimmer picture emerges. I have said that this is no place for rose-coloured spectacles. There can be few areas of endeavour where so many resources, so many billions of pounds and dollars and francs and yen, have been expended for so many decades to so little effect. Promises of breakthroughs, yes. Actual effects on the mortality figures of breast and other major cancers, no. This is not a layman's view: you can read it almost any day in the medical press. Last year, on 6th February 1993, the Lancet published a challenging editorial entitled: Breast cancer: have we lost our way? After cataloguing some of the failures of the past, due largely to, the extraordinary capacity of the profession for self-delusion", it asks, would it not be more scientific to ask why this approach is failing and recognise that any more of the same could be the medical equivalent of the surgical excesses of the middle years of this century? This editorial foreshadowed a breast cancer conference held in Belgium last month. With growing dismay, but perhaps with rather less surprise, I read the summary report of that conference: Have we lost our way? … With confidence we can say no …". There was little hint of recognition of the seriousness of the situation, the prescription being roughly for the mixture as before, and I was left wondering what other profession could show such calm assurance in the face of so many years of conspicuous failure, and still retain the respect of government and public.

The noble Baroness knows, because I have referred to them before, that there are a number of alternative approaches to breast and other cancers, and I hope she may agree that the time is right for some more radical thinking in this direction. I know that the noble Lord, Lord Colwyn, would agree. The US Congress Office of Technology Assessment published a report on them in September 1990, and I have asked for a copy to find its way into the Library of your Lordships' House. Let no one think that so-called alternative treatments are good for hay fever and mild psychosomatic complaints but lack a real punch when it comes to the big league. When you cease to focus on the rogue cell, tumour or virus and concentrate on massive reinforcement of the host body and its immune system it is remarkable what can be achieved, as many cancer survivors will testify.

It is not that these treatments have been examined and found wanting: they have never been properly looked at. But it demands new thinking, and a willingness to learn, and it seems to me that both these qualities are in short supply in the cancer field at present. It also demands a better scientific attitude than was brought to the study of the breast cancer patients at the Bristol Cancer Help Centre, whose publication in 1990 did so much harm.

Interestingly, however, only a month ago a report appeared in the press which some of your Lordships may have seen about the apparent recovery of some Danish breast cancer patients in a study on a fruit and vegetable diet with vitamin supplements. These are by no means the only examples I am aware of from that particular nutritional field.

My Lords, we need rapid improvements in the treatment of breast cancer, and I fully support the noble Lord, Lord Ironside, in the case he is making. It should be possible to bring most centres and regimes up to the standard of the best. But my wider concern is that the best is still, in absolute terms, pretty bad. I greatly doubt that the situation will change until there is a real willingness to explore other avenues which have shown promising results, if need be from other cultures. I am convinced that anything which the noble Baroness can do to further research in this direction will prove immensely worth while.

Viscount Brookeborough

My Lords, I, too, thank my noble friend Lord Ironside for initiating this debate. I wish to declare an interest and, in doing so, explain why I, as a total lay person in these matters, am taking part in this debate. For just over a year I have been a non-executive director of the Green Park Trust group of hospitals in Belfast. Within that group we have Belvoir Park Hospital, which contains the regional oncology unit for the whole of Northern Ireland. I ask my noble friend the Minister: why on earth was Northern Ireland not included in this consultative document by the Expert Advisory Group on Cancer? The Minister will no doubt say that it is an advisory group for chief medical officers of England and Wales. However, I notice that the Scottish Office was included while the Northern Ireland Office was not.

In case there should be any doubt about the quality of care in the Province, on the fringe of the United Kingdom, I would like to point out the following general points. First, we have in the Green Park group the largest and most modern joint replacement unit in the United Kingdom—1,700 joints last year. It has the only on-site joint factory in the United Kingdom, which uses x-rays and computers to make them. Where else can you be measured up one day, fitted the next and back home in five days? Secondly, we have the most sophisticated gait analysis laboratory in the UK. Thirdly, coming to cancer, we have one of only two (so far as I know) intensive therapy units—the modern equivalent of bone marrow transplant units—so there is no lack of quality provision to call on. In addition to all that, according to RAGE, we have had only one incident of significant brachial plexus injury, and that was in 1989.

The question has to be asked: why exclude the Province, especially when its size of population falls directly in line with what is recommended in paragraph 3.3.5 of the consultative document and it would therefore seem to be an ideal sample unit?

I can see that the consultative document is a very valuable piece of work. But it has fairly long-term planning and financial implications. I would like to look at and discuss how immediate improvements with few financial implications could be made to the diagnosis and treatment of breast cancer.

It is not for me to argue for the increase or otherwise in the age bracket for recommended cancer scanning. However, more encouragement should be given to people within those age groups to attend. In rural areas in Northern Ireland the uptake is fairly good. However, more must be done in urban areas. The health department should look not only at its advertising but also at the location and accessibility of its units in built-up areas.

We already have six breast cancer clinics where women may go. There they may be given fine needle aspiration (FNA) if necessary and can be told immediately of any problem. This is a good system. However, there is an alternative; namely, the old system whereby women can go to their GP, who may use his own judgment as to whether to refer the patient to the general hospital. I would suggest that that is not good practice and, if in doubt, all GPs should be obliged to refer patients to breast cancer clinics for FNA, and so obtain a surer diagnosis from stage one. I realise that there may be a problem with the supply of histopathologists. However, since the life span of samples is, I understand, from two to three hours, it would be quite possible to centralise that part of the service and the test could be done very quickly.

From that point, patients diagnosed as having the disease go to a hospital and are operated on by, more often than not, a general surgeon. Many of those surgeons may see only half a dozen breast cancer patients in a year. That cannot be good practice. Rather than many surgeons doing a few operations, it must be right to reorganise their allocation of operations so that most, if not all, cancer operations are carried out by a reduced number of surgeons. Even without additional training they would become more specialised by practice. At this stage, it is the surgeon's opinion as to whether or not to refer the patient to the regional oncology unit—in our case, Belvoir Park Hospital.

It is my impression that up to this stage we have too many unspecialised people taking decisions on referral and all too often obtaining no specialised advice. In Northern Ireland out of 5,000 cancer patients a year of all types, only about 2,800 were referred last year. That seems to reflect the national average.

For those with breast cancer who are referred to an oncology unit, there are variations of technique and treatment throughout the UK, some of which may result in lower quality of treatment and complications, such as brachial plexus injury. It is thought that certain techniques might carry a higher risk of injury, but no one knows which are involved. Therefore it is not any lack of quality in the oncologists but the lack of research that is at fault. We must await the results of analysis of the information that will be contained in cancer registers.

Meanwhile, it appears that although all oncology units have a medical physics department, it is not always consulted in the planning stage of treatment. It is equally important to decide not only whether to use radiotherapy but also the size and number of fractions used and the target areas. Fear of leaving large gaps in the junctions between fractions should not lead to too much overlapping, which perhaps carries a higher risk of injury. It could be suggested that the planning by medical physics departments is more important than some oncologists might believe. Every case is different and the medical physicists must be of a uniform standard and must be consulted.

Consideration should be given to such matters as stronger fractions and a smaller number of treatments or weaker fractions in a large number of treatments. Although the treatments are cumulative in strength, it is important to note that cancer cells react to different strengths of treatment compared to nervous tissue. Much more research needs to be done. We hope that the Government will encourage it.

In conclusion, the way forward seems to be indicated by the consultative document prepared by the expert advisory group in the medium term. In the shorter term, much improvement could be obtained with more consultation vertically and laterally within the medical profession, together with some administrative reorganisation, to achieve maximum availability of quality treatment. Clinical directors must be given guidance on how to implement immediate change, where it can be carried out in the short term. In their trust status, this will be new to them, as it used to be the task of the department. They need leadership. I hope that in future Northern Ireland will be consulted when this problem is further examined.

Lastly, there has been talk of counselling, especially on the patient's side, which I support. At Belvoir Park Hospital consideration is being given to counselling of oncologists and the other bearers of bad news. There seems to be room for such counselling. They have an extremely hard job to do. We feel that counselling will help greatly to improve their methods and their efficiency.

4.12 p.m.

Baroness Robson of Kiddington

My Lords, I also should like to thank the noble Lord, Lord Ironside, for raising this subject, which is of such intimate concern to women.

Cancer in general is mainly a disease of the elderly and is increasing in our society. That is not so astonishing because the age of the population is also increasing. But breast cancer is quite different. First, it is tremendously difficult to diagnose early enough. It has a tremendously high incidence and death rate. There are 30,000 women diagnosed as having breast cancer every year.

The problem with breast cancer is that there does not seem to be a single identifiable factor which causes the disease. We are quite happy to assume that cigarette smoking is responsible for lung cancer. I say "assume" because I am a smoker, although I accept that it is a correct diagnosis. It is certainly thought that a high fat and low fibre diet could be a factor in breast cancer. Breast screening, either through self-diagnosis or through the NHS programme, has had a small impact, but has not significantly reduced the death rate.

Dr. Beral of the Imperial Cancer Research Fund has carried out some studies. She recorded a fall of 400 in the death rate from cancer between 1989 and 1992. She states that it has been known for some time that having children, especially having the first at a young age, reduces the risk of breast cancer.

After the Second World War the average age when women had their first baby fell from 26 to 24 and the percentage of childless women halved from around 20 per cent. to 10 per cent. It is in those women that the breast cancer incidence has fallen. By contrast, the women with increasing death rates were those of child bearing age at around the time of the depression when many women put off having their first child until much later or had no children at all. That is a theory of Dr. Beral. If there is anything in it, it is worrying that the present population of women who want to develop a professional career are putting off having their children later and later. It is therefore something which should be investigated.

One feature of the treatment of breast cancer is that it can sometimes be many months after the initial visit to the GP before the diagnosis is made, and then there is a further delay before treatment is started. When the diagnosis results from screening, the process is usually quicker and the patient usually has surgery within four weeks of diagnosis. However, it may take several more weeks before radiotherapy begins. In some cases that may be due to the fact that hospitals with radiotherapy departments have insufficient funding and as a result considerable delays may occur. Also, as a result of the reforms in the NHS, the service is not now under regional control. The way it now works is through local purchasers buying treatment. As a result, sometimes through lack of money, many purchasers put their emphasis on less specialist services. Lack of resources increases the risk of errors. Examples of that have given rise to the recent problems with radiotherapy such as the cases in Stoke where underdoses were given and in Exeter where overdoses were given.

The Department of Health is now doing something about the issue of central advice to purchasers. But it is important that we make certain that the lack of resources is not the reason for the treatment not being given efficiently or on time. Of course, breast cancer patients can obtain high quality service in most units, and in low quality units patients are beginning to realise that they can demand better service. But there are still a large number of patients in the NHS who are not receiving good service and the division of hospitals into individual provider units will cause that number to increase.

Errors can occur in any form of treatment. Systems of quality assurance and quality control for radiotherapy are developed and are used, but again there can be errors along the line. If resources are not enough, there may be shortages in the number of physicists and radiographers so that they are working beyond their normal hours. Errors can creep in through fatigue. It appears that lack of resources is directly linked to errors. It is directly linked to the overdosage incident in Exeter which was partially the result of there not being enough physicists and consultant oncologists. In addition, the management structure was poor so that there were unclear lines of responsibility.

The same faults occurred in Stoke where under-dosages were given. The staffing levels of radiographers and the provision of equipment were below the recommended levels. Again, insufficient physicists and oncologists were employed. This has now been rectified in those two centres, but the accidents have shown that there should be regular monitoring in all centres to ensure that there is good quality control and that clinical audit is carried out.

Recently a survey has been conducted by the Royal College of Radiologists of equipment and non-medical and medical staff in all regions. This has pinpointed the fact that there is no way in the present purchaser-provider system of ensuring that when equipment is wearing out there are funds to replace it. The survey also showed that one of the main causes of stress was not having enough time with patients to give the standards of care that doctors felt was necessary. In this country we have 272 clinical oncologists funded by the NHS and 65 medical oncologists mostly funded by cancer charities. This is the lowest number of cancer doctors per head of population in Europe, apart from Portugal. On average a clinical oncologist sees 560 new patients per year. Those patients are then on that doctor's list for at least five years. So the average number of patients under the care of an oncologist is 2,000 at any time; again not enough time to deal with patients in depth.

There is not always an understanding among the public that all medical treatment will have side effects. That is so with radiotherapy perhaps more than any other treatment. Because it does not look as if anything is happening during treatment, patients completely fail to realise that it is a serious treatment, like major surgery. The long-term side effects can be severe and that needs to be explained to patients. However, good treatment should keep the side effects to a minimum. For most patients with breast cancer radiotherapy is a major treatment for all stages of the disease. It has been proved that radiotherapy increases survival as well as controlling local disease. Therefore it is most important that radiotherapy techniques are good and, whenever possible, improved to minimise long-term side effects.

It follows from this that what patients need most of all is counselling and time to decide which treatment to use. They also desperately need the help of a breast cancer nurse to give psychological support and information. I welcome the Macmillan breast cancer research campaign and the distribution of 3 million leaflets round the country to help women to help themselves. Because of the fear of cancer people withdraw into themselves. They do not want to discuss it. That does not help when it comes to seeking treatment in time. The counselling women need both from their doctors and their nurses is one of the most important helps we can give them.

4.23 p.m.

Lord Rea

My Lords, like other noble Lords and noble Baronesses—I anticipate the Question of the noble Baroness, Lady Castle, on 6th June to ask why when we speak of other noble Lords we include noble Baronesses; and noble Baronesses in this debate are playing a major role—I thank the noble Lord, Lord Ironside, and Lady Ironside for bringing this issue into the public arena.

Following the RAGE press conference in September of last year, the very dignified article of Lady Ironside in the Parliamentary Brief last October and the two Questions asked by the noble Lord in this House, the issue has been brought into the public eye. Perhaps Lady Ironside's intervention has accelerated government action.

The visible evidence of that has been the recent and excellent consultative document which other noble Lords have referred to. It is published by the department and by the Expert Advisory Group on Cancer chaired by the Chief Medical Officer. There is also the Department of Health's publication Quality Assurance in Radiotherapy which has been quite difficult to find. The one I have arrived only this afternoon.

I am not asserting that RAGE and the noble Lord were the only influences in getting these publications produced for us. But it is interesting that both reports were published only just before the noble Lord's Unstarred Question. Unlike many Department of Health documents, these documents were not published in a glossy, expensive format. They are quite stark in nature. One has a plain blue cover and the contents look as though they came straight off a word processor. That is no criticism. In fact both reports are extremely useful, particularly the consultative document which has wide-ranging recommendations that I do not believe will be very popular with some surgeons and radiotherapists, especially those working in isolation, and perhaps with some of the 53 centres which may be superseded if the recommendations of this report are carried out. I wish that some other publications of the Department of Health had been so concise, authoritative and businesslike. I am sorry that there is not a fuller bibliography such as that in the excellent Scottish Home and Health Department document on Scotland's diet, which is a model of how such a critical and important topic should be presented. But perhaps rapidly produced reports may be excused such academic finesse.

The consultative document has one deficiency. It completely omits discussing the prevention of cancer. It is true that its remit was to consider treatment services. However, other noble Lords have spoken about prevention and that is in order in this debate. As many noble Lords have already said, this country has the highest rate of breast cancer in the developed world, as well as the highest mortality rate from breast cancer once it has been diagnosed. That means that it is the highest in the whole world because the developed world has higher cancer rates than in the developing world, unlike many other diseases. This is a disease which comes from affluence, if you like, and living in the somewhat artificial environment that we perhaps have in the industrialised North.

Perhaps this is not the occasion to inquire why the rate of cancer is so high in the United Kingdom. The reasons are not fully understood, of course. There are many factors to consider and no one of them is the whole answer. The noble Baroness, Lady Robson, described what is probably the most important factor; namely, the late starting of families. The condition is more common in those of higher social class. That is the section of the population where women are educated, start careers and put off having a family more than at the other end of the social scale. Diet has also been mentioned and alcohol consumption may play a part.

The part played by these various factors will become clearer as current and ongoing research is completed, as well as much needed further research.

Here I have to declare an interest, as my son is a trainee oncologist who is at present doing his PhD at the Imperial Cancer Research Fund's laboratories.

What concerns us today is why breast cancer is more likely to kill women in the United Kingdom than in other countries. One possible reason for that is that British women are less likely to present breast disorders to doctors at an early stage than are women in other countries. There is possibly a very British reluctance by women, particularly older women, to know and physically to feel their own bodies, especially the sexual parts of their bodies, than is perhaps the case in other countries. There is a hesitancy to seek medical advice. Two years ago the British Medical Association produced a video with an accompanying text called "Preventing Cancer" for the use of general practitioners and nurses in primary health care. It stated: Women should be familiar with the feel and appearance of their breasts. This should not only help women to detect lumps at an early stage but should reduce anxiety about the normal changes which occur during the menstrual cycle … Breast self examination is a skill which ha; to be taught". That brings me to the role of the general practitioner which, as other noble Lords have pointed out, is absolutely crucial. I do not think that all GPs are referring early enough although most do and are careful and thorough when a woman presents them with a breast problem. I deny what the noble Lord, Lord Colwyn, said —that some GPs try to look after cancer cases themselves and do not refer them. I think that if a GP does that, he is guilty of negligence. The only case in which a GP should hang on to a cancer patient and not refer is that of a very old or debilitated person who perhaps could not stand an operation or a course of radiotherapy or chemotherapy.

Postgraduate education, as well as good under-graduate education, is absolutely essential. The present system of postgraduate education, in which part of the pay of GPs is withheld unless they attend a minimum number of postgraduate sessions, is working. But the detection of early breast cancer is a very practical skill. It is not always easy, if I may coin a phrase, to lay on patients on whose breasts doctors on postgraduate courses can lay their hands. My rule as a GP has always been: when in doubt, refer. I think that the great majority of doctors feel the same way. I have been particularly lucky in having specialist breast clinics in two hospitals within a two-mile radius, one being the Royal Free Hospital which is now under the jurisdiction of the noble Baroness, Lady Gardner of Parkes! Both clinics have a very short waiting list.

Reference has been made to the National Breast Screening service, which was set up following the Forrest Report. That looks like becoming a success story although there is still too wide a variation in take-up —for instance, 60 per cent. of women in the eligible age groups take it up in Kingston and Esher while 74 per cent. do so in Southport and Formby. That difference in take-up rates is associated with quite a big difference in the breast cancer death rates in the two areas. I am not saying that that is necessarily due to the effect of screening. It is probably due to the attitudes of the women in the two different areas and perhaps to the breast cancer services there and the women's faith in them so that in Lancashire women are more likely to present early while women in Kingston are less likely to do so.

With regard to treatment centres, I am sure that the recommendations of the Expert Advisory Group on Cancer are on the right lines. The recommendations state: Improved outcomes are associated with specialised care for uncommon cancers and many studies also suggest this association for common cancers", of which breast cancer is the commonest, although deaths from breast cancer are now being overtaken by deaths from lung cancer in women because of the difficulty that women have in giving up smoking.

Some of the rather heroic and higher dose courses of radiotherapy to which some members of RAGE were exposed, have already been modified and improved. For instance, routine axillary irradiation which used to be more common has largely been abandoned. It should be emphasised though that the local variations in radiotherapy practice, pointed out by other noble Lords, are now being addressed—they are still there—by the Royal College of Radiologists, with the support of the Department of Health.

The 1991 report of the Standing Medical Advisory Committee entitled Quality Assurance in Radiotherapy has been followed up by this very recent large document which I am afraid I have not had time to read. It will be interesting to hear from the Minister how the 1991 SMAC recommendations have been followed up. The 1991 report sets out 18 requirements, covering the entire process by which radiotherapy is delivered to the patient. However, as has already been pointed out, a survey reported in the BMJ earlier this year suggested that many deficiencies remain. There are other initiatives, which I shall not go through—I have occupied too much time already—in train, studying what is going on, with the possibility of speeding up the improvements for which we are all hoping.

All that will be made easier if the recommendations of the expert committee are accepted. I shall give just two of its recommendations. Recommendation (iii) states: Cancer Centres and Cancer Units should be established to provide an integrated network of cancer care. Communication between … centres is vital". Recommendation (iv) states: There should be a clear understanding of appropriate referral and follow up patterns between General Practitioners, Cancer Units and Cancer Centres. These should be based on agreed guidelines and information on quality and outcome of care". There are 13 recommendations in all.

Finally, I take up a point raised by the noble Baroness, Lady Robson. Manpower and resources must be discussed. There seems little doubt that even though we have the highest rate of breast cancer in the world, the resources devoted to cancer care are considerably less than in other countries. That has been pointed out by several other noble Lords. The noble Baroness, Lady Robson, described the shortage of oncologists in this country compared with France, Germany and the USA which have almost twice as many oncologists per head of population as we have. It is clear that the number of oncologists needs to be increased, but in the past two years only 32 extra were appointed.

There is also little doubt that the NHS is overall a cost-efficient service, but there are areas—this is one of several—where resources are stretched dangerously thinly, too thinly to be efficient and safe. The noble Baroness pointed that out clearly. I am afraid that the sad stories we have heard today bear that out fully, even though rather late in the day the Government now appear to be acting.

Lord Colwyn

Before the noble Lord sits down, perhaps I may say that I did not intend to imply any criticism of GPs. I intended to say that, because of the relatively small numbers of patients they saw, I felt that they may not have the experience to know whether to refer or to watch for a little longer. I was not intending any criticism.

4.40 p.m.

Baroness Cumberlege

My Lords, the Government are most grateful to my noble friend Lord Ironside for bringing this matter to the attention of your Lordships' House. As your Lordships will be aware, my noble friend has worked tirelessly to increase the knowledge of the public about the vexed issues concerning breast cancer and in particular the need for an assured standard in the quality of radiotherapy treatment.

The practice of medicine, like many aspects of modern life, is becoming increasingly complicated. The ability of the health service to offer sophisticated cancer treatments is to be applauded, its potential encouraged and its continuing development informed by up-to-date research. However, the possibility of causing harm has also to be recognised. The Government want people to have justified confidence in their health service and to know that the treatments available are effective and safe.

The diagnosis and treatment of breast cancer are a government priority since each year around 25,000 women in England will be diagnosed and, tragically, around 13,000 women will die prematurely from the disease. Many of those lives can be saved if the cancer is spotted and treated at an early stage.

Prompted by this sad loss of life, and encouraged by the results of multi-centre trials, in 1985 the Government established the Forrest working group. The group's report recommended the introduction of a national population breast screening programme, the first in the European Union, whereby women between the ages of 50 and 64 should be called for three-yearly screening by mammography.

Between 1987 and 1990, £70 million was allocated to set up and run the breast screening programme. Resources were invested in four national initiatives: education and training, quality assurance, equipment and information systems.

As was said by the noble Lord, Lord Molloy, the noble Baroness, Lady Robson, and my noble friend Lady Gardner of Parkes, successful treatment depends on the early detection of breast cancer. I know that that view is not shared by the noble Earl, Lord Baldwin, but work on cervical cancer screening has shown a reduction of one-third in cervical cancer in women who have regularly been tested. That is why we have made such efforts to establish specialised breast screening centres nationwide.

It is essential that all local screening programmes have reliable quality assurance systems. These are monitored to ensure that abnormalities detected by mammography screening are investigated as soon as possible.

The Government have a clear objective to reduce mortality and morbidity caused by all cancers. Breast cancer screening offers an effective and measurable intervention in reducing deaths and is a key priority in the Health of the Nation strategy.

But of course we recognise that this cannot be achieved without the help of others. Last week, as your Lordships mentioned, the Cancer Relief Macmillan Fund launched its breast cancer initiative. We welcomed that campaign, which is entirely consistent with our wish to empower patients to give them more confidence to question diagnosis and to exercise choice in their treatment. We want them to be active partners in their care. We also recognise the significant contribution made by other voluntary groups working in research, working with ethnic minority groups and with homeless people raising cancer awareness.

It is vital to have a high quality service for women who believe that they may have breast cancer. The Government's Chief Medical Officer has written to all doctors in England giving advice on the ways in which women can be involved in early detection, outlining the key symptoms and signs.

We now need to ensure that all women with breast cancer receive the best care available. The chief medical officers of England and Wales recently published their consultative report on the provision of services. The report was welcomed today by your Lordships and also widely outside the House. The report, prepared by an expert advisory group which included leading cancer specialists, has far-reaching implications for the future organisation of services.

The report sets out general principles which should govern cancer care. These principles include the need to involve not only patients, but their families and carers; to give them clear information about treatment options; and to respect their views. This seeks yet another change in culture, but health services are beginning to accept the notion that the patient's own opinion is not just relevant but of overriding importance; and it can affect the speed of recovery.

Another principle in the report is that all patients should have access to a uniformly high quality of care. The report proposes a network of expertise at three levels with the patient's own doctor playing a crucial professional role, not only in terms of the initial diagnosis, treatment and care, but guiding, supporting, informing, advising and above all listening to the patient and her family. Throughout the whole episode of treatment and care, wherever that may take place, the linking professional should always be the GP.

Recently, there has been criticism of the referral of women to cancer specialists. We understand the anxiety and trauma of those who believe they may have breast cancer. That is addressed in the report, which recommends that there should be detailed discussions between all the GPs in an area and the local hospital service to clarify patterns of referral and follow up.

The second level of care is to be provided by cancer units in local hospitals. Those designated units will treat the more common types of cancer. It is recognised that, in order to gain enough knowledge and expertise, a sufficient volume of work is necessary. The expert advisory group will be discussing with the relevant professional bodies the workload necessary in each hospital to achieve universally the high standards of clinical practice which we seek.

We recognise that many cancer units will not have a sufficient workload to justify the development of services for the more rare and unusual forms of cancer. We are therefore planning for cancer centres which will serve a population of about 1 million. Those centres will also provide services for their local population in the same way as cancer units, in addition to giving the highly specialised and sophisticated treatment to the small minority of women who need it.

The report has far-reaching consequences for the organisation and provision of services. We will, therefore, consult widely and listen carefully to all the views expressed before deciding on how the report's recommendation should be taken forward.

We strongly support the view of the noble Countess, the Countess of Mar, that every woman should receive information on the options available and be offered a choice of treatments. Recent studies of adjuvant therapy indicate that a combination of treatment—surgery, radiotherapy, chemotherapy, adjuvant endocrine therapy—is highly effective, but circumstances differ in individual cases.

Assessing the outcome of different treatment regimes is complex. As my noble friend Lord Brookeborough so clearly explained, treatment depends on a range of factors including cancer size, stage, site, and the overall health of the individual woman. Benefits and side effects may take years to become apparent. But the expert group not only draws attention to the work already done in setting standards for quality assurance and radiotherapy. It also draws attention to the need to pursue clinical audit. With greater concentration of service and expertise, that will be easier and more effective. We would expect nurses to be closely involved in audit because we know that they play a crucial role in supporting women and their families prior and post diagnosis and In any treatment and care which follows.

As my noble friend Lady Gardner and the noble Lord, Lord Molloy, said, breast cancer nurses play a crucial role in answering women's questions and explaining treatment options. However, I am sure that my noble friend will support me when I remind your Lordships that staffing in local units is a matter for local decision and we should not wish to direct it from the centre. The expert group on cancer recommended that patients should be seen by appropriately trained members of a multi-disciplinary team.

My noble friend Lady Gardner, the noble Baroness, Lady Robson, and the noble Lord, Lord Rea, addressed the need for an increase in breast cancer specialists. The expert group on cancer believes that there may be a need for more cancer specialists. However, much can be done in organising the existing services better so that doctors become increasingly specialised instead of treating the broad range of diseases.

The number of oncologists in this country is lower than in other European countries, and that is for historical reasons. Oncology specialists are increasing in number more rapidly than other specialists and we now have 200 clinical oncologists in England and 30 medical oncologists, with more than those numbers in training.

Increasingly health professionals acknowledge that a holistic approach to treating patients is not only appropriate but more effective. This is particularly important in a disease like cancer, which is always frightening for patients and their families and for which conventional medicine does not always have the complete answer.

I agree with my noble friend Lord Colwyn that there are many factors which influence cancer. Complementary medicine may have a place in the treatment of many diseases. It is encouraging that the British Medical Association has recognised this in its recent publication Complementary Medicine: New Approaches to Good Practice, and I welcome the increased communication and collaboration between the mainstream clinical professions and other therapists.

Many complementary therapists have a valuable place in the provision of health care but they also have a responsibility to the public. That form of health care should, therefore, be subjected to the same rigorous evaluation and audit that is applied to conventional medical practice.

Radiotherapy has been used to treat cancer for nearly a century. In those early years treatment machines were completely unprotected and were dangerous to staff and could not be directed with any precision. By the outbreak of the First World War, a number of major radiotherapy centres had been established, including the Christie Hospital, the Holt Institute and the Royal Marsden.

I think that I can say with some confidence that we have moved on and we have learned from those early years; but we are still learning. Future advances are expected in biological techniques to identify those patients with increased normal tissue sensitivity. That will enable individual treatment to be tailored more precisely.

Your Lordships may be aware of the 1991 publication entitled Quality Assurance in Radiotherapy. That document sets out 18 requirements to be satisfied to ensure that quality in radiotherapy is maintained. Quality assurance is defined by the British Standards Institution as, all those planned and systematic actions necessary to provide adequate confidence that a … service will satisfy given requirements for quality". In the light of that report, two clinical oncology centres were funded by the department to undertake pilot studies on how best to implement quality standards, and to prepare manuals which might serve as a model for use by other radiotherapy centres. The results are set out in a document drawn to our attention by my noble friend Lord Ironside entitled, Quality Assurance in Radiotherapy—A Quality Management System for Radiotherapy, which has been widely circulated. However, it is an advisory document—a tool which we hope the NHS will find helpful in providing services.

I agree with my noble friend that it is important for all radiotherapy centres to have good quality assurance systems for radiotherapy. That is to be encouraged. However, BS 5750 is only one such system and offers no guarantee of a quality service or improvements to clinical practice if the quality systems are themselves inadequate or if clinical protocols are not right.

The noble Lord, Lord Molloy, sought some reassurance about funds for research. In 1992–93, the Government spent over £3.8 million on breast cancer research, £3.1 million of which was commissioned through the Medical Research Council. Government expenditure of £3.8 million on research into breast cancer in 1992–93 does not include clinical research supported through local NHS research programmes or excess service costs for the NHS attributed to breast cancer research. It is estimated that in 1992–93 the major cancer research charities spent £8.7 million on breast cancer research, thus giving, with the Government's contribution, a total identified spend of £12.5 million.

My noble friends Lord Ironside and Lord Brookeborough asked why Scotland and Northern Ireland were not part of the review. First, perhaps I may reassure my noble friends that there is no evidence of a North-South divide, nor, so far as I am aware, any evidence of an East-West divide. My noble friends can take some comfort from the fact that the Quality Assurance in Radiotherapy treatment document sets standards and has been commended to centres in Scotland and Northern Ireland by their chief medical officers. I am sure that those two countries will also be interested in the framework document which we have just launched. However, your Lordships will be aware that both those countries have their own health Ministers, health officers and structures.

The noble Countess, Lady Mar, asked why it had taken us so long to produce the policy document that was launched last week. There are a number of reasons. First, we wanted to ensure that the screening systems were in place, because our priority had to be early detection. Secondly, we had a great deal of work to do to prepare the ground, not least in terms of clinical audit. That concept is now well established in the NHS and the preparatory work on quality assurance is complete, especially for radiotherapy. Thirdly, we wanted to ensure the co-operation of the professionals involved. We believe that we have that now and that they support in principle the proposals in the document which we launched last week.

The noble Baroness, Lady Robson, asked about other staffing levels. She referred to the incidents at Stoke and Exeter which occurred some years ago. I believe that in the case of Stoke the problems started in the early 1980s and in Exeter occurred in 1988. Since then there have been increases in the recruitment of medical physicists throughout the country, including in both those areas.

The noble Baroness also asked about funds for replacing worn out radiotherapy equipment. The Government have recognised the need to replace old radiotherapy equipment. To speed up that replacement, a three-year programme of £15 million a year was set up from 1992–93 to cover the purchase of expensive equipment, including linear accelerators for cancer treatment as well as diagnostic equipment such as mammography units.

The noble Lord, Lord Rea, asked why we had the highest incidence in the death rate for breast cancer in this country. It is true that we have a very high incidence, but it is not fully understood why that should be so. One of the reasons that has been suggested is that in this country we have a very good system of cancer registration. We believe that if we are doing this better than other countries then we may have an apparently poorer record in terms of the incidence of cancer.

In conclusion, there are many women alive and well today who owe their lives to the progress that has been made in the detection, diagnosis and treatment of breast cancer. The service in general is good, but we want to make it even better. To that end, we have drawn up a blueprint for the future which we want widely discussed and debated, not only among professionals in the health service but by all those who have an interest in the subject.

Finally, I should like to say to my noble friend Lord Ironside that we are very aware of his concern about radiotherapy treatment and his and his wife's involvement in the organisation RAGE. He has been kind enough this afternoon to mention my personal interest in those women who have suffered side effects following such treatment. I thank him for the detailed information which he and RAGE have submitted to the Department. I am conscious that our policies are for the future and that it is right that we must go forward, but I cannot ignore the past.

I have discussed this matter at length with the Chief Medical Officer for England and he has agreed to establish a small group of professionals and lay people who over the next few months will consider guidelines for care for the group of women who have suffered tissue damage following radiotherapy for breast cancer. I hope that that will go some way to reassure my noble friend as to the seriousness with which we address this issue. Once again, I pay tribute to him for his diligence in pursuing the matter and in seeking to take it forward.

Lord Ironside

My Lords, before my noble friend sits down, perhaps I may ask her a question in connection with the clustering of radiotherapy treatment injuries which have occurred. Can she go further and say to what degree she is prepared to look at the situation from the point of view of an audit to see what happened and where and why it happened, with a view to preventing it happening in the future?

Baroness Cumberlege

My Lords, that is a separate point. My noble friend is due to meet the. Chief Medical Officer for England and also the President of the Royal College of Radiologists to take the matter forward. I suggest that that is the forum in which he should raise the question and receive an answer. I am concerned with the women who have already suffered through radiotherapy treatment and how best we can look after their interests.

House adjourned for the Spring Bank Holiday at one minute before five o'clock.