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5.41 pm
Mr. John Austin-Walker (Woolwich): I share the view of the hon. Member for Colchester, South and Maldon (Mr. Whittingdale) that it is surprising that there is not more publicity about this matter. I doubt that there is anyone in the Chamber who is not either close to or who knows someone who is suffering or has suffered from breast cancer. I hope that the efforts that the national coalition has begun to bring groups together to give a much higher profile to breast cancer will succeed. I am sure that those efforts will receive support from all right hon. and hon. Members.
Hon. Members have referred to the fact that the incidence of breast cancer in the United Kingdom is not particularly high by international standards, yet we have the highest recorded rate of mortality in the world. They have also spoken of the regional variations. There may be some arguments to the effect that data from other countries may not be comparable with ours. However, all the witnesses who gave evidence to the Select Committee concluded that even if Britain did not have the highest mortality rate in the world, it was one of the highest, and that it deserved urgent attention.
In the United Kingdom it should be possible to rely on comparability of the data. In that context, the regional differences that have been highlighted are somewhat alarming. Some reasons have been advanced for those regional differences, but most members of the Health Select Committee came to the conclusion that the major reason for the differences in mortality was probably the poor treatment of the disease in some areas. I certainly believe that that is the most convincing reason.
We know that the treatment that women get depends on where they go. The Select Committee heard much evidence, and there is more evidence from other sources--anecdotal and statistical--that many women do not get a quality service or appropriate treatment. It would be foolish to suggest that early diagnosis and early, appropriate treatment will lead to a successful outcome in all cases. However, if detection is not early or treatment is delayed or inappropriate once the disease is diagnosed, the consequences will--almost invariably--be tragic. The Select Committee concluded that it would be possible to reduce the number of deaths from breast cancer each year by some 4,000, if we had a standard quality of service throughout the country.
Some people have criticised the Select Committee and the Government for putting too much emphasis on breast screening. They have suggested that screening is costly and detects only a minority of cancers. The latter is true and I share the view that we should always examine the cost-effectiveness of all screening programmes. However, I remain convinced that the screening programme should be maintained and improved as part of the overall strategy for detecting breast disease and reducing breast cancer mortality.
The quality assurance programme referred to by the Chairman of the Select Committee is vital to ensure that the same high-quality service is available throughout the country. My hon. Friend the Member for Fife, Central (Mr. McLeish) expressed concern about the relationship between quality assurance teams and purchasers,
following the proposed move from regional purchasing quality assurance to district health authority lead purchasers. As the Select Committee's report says, district health authorities
Since the Select Committee report, there have been some developments in the way in which mammography is carried out, which we all hope will lead to a reduction in the number of false negatives and false positives. The possible tragic consequences of a false negative are only too apparent. More accurate diagnosis and early detection can lead to early and appropriate treatment. As my hon. Friend the Member for Fife, Central said, that can lead to more years of life of better quality.
We should not underestimate the effects of false positive results, which the national co-ordinator described as a "downside to . . . screening". Such false positives not only cause great anxiety and in some cases severe psychological trauma, but they lead to women undergoing unnecessary recalls, further unnecessary clinical investigations, and in some cases unnecessary diagnostic surgery. I appreciate the view expressed by Hazel Thornton of Radiotherapy Action Group Exposure, who described the programme as
The Select Committee believed, however, that there is definite evidence that screening by mammography is effective in reducing breast cancer mortality, certainly in women over 50. Evidence in the Forrest report convinced me that the only way substantially to reduce the number of deaths from the disease is detection before the patient presents with symptoms.
The Select Committee takes the view that it is perhaps too early to make final judgments about the efficacy of the breast screening programme, because of the lead time. We need to observe the mortality information about 10 years from the introduction--after 1997--to get a more accurate picture. I believe that we will see then that the programme has been efficient and effective.
The Committee has highlighted the problem of women placed on early recall, which might mean a wait not of a few weeks, as was suggested earlier, but of six to 12 months in some cases. Such insensitivity can lead to great anxiety, and in many cases acute depressive illness can follow. That is why I, and other members of the Select Committee, urge the establishment of the one-stop shop. That may not necessarily reduce the time between screening and assessment, but it could significantly reduce the time between assessment and diagnosis and considerably minimise anxiety. That is why I believe it important to carry out the recommendations of the Forrest report for routine assessment teams comprised of clinicians, a radiologist, a pathologist, a radiographer, a
receptionist and a breast care nurse. Breast cancer screening is not just to do with mammography; it includes all stages in the diagnosis of the disease.
As the hon. Member for Broxbourne (Mrs. Roe) has said, it is generally accepted that there is little benefit in routine screening of younger women, but I believe that further research needs to be done to determine whether there are readily identifiable groups among the younger age groups who may be at higher risk and among whom prevention can be undertaken.
The Committee was convinced of the efficacy of the screening programme for women over the age of 50, and firmly recommended that the upper age limit for inclusion in the call and recall system be extended to 69. The evidence for that is clear, and in this respect I found the Government's response extremely disappointing. I am firmly on the side of Age Concern, the British Medical Association and the Society of Radiographers. The decision to establish some demonstration projects may be a start, but it is not enough and it is quite disappointing.
I urge the Minister to reconsider the Select Committee recommendation. What extra resources are being provided for these demonstration projects? The Government talk about advertising the fact that women over 65 are entitled to be screened every three years. I should like to know what resources have been allocated for extra screening to take account of increased take-up by the over 65s. Without such extra resources it will not be possible to screen more elderly people.
Effective diagnosis is one thing: treatment is another. We have anecdotal and statistical evidence to show wide variations in treatments and outcomes. One thing is absolutely clear from the evidence--surgeons who treat more than 30 cases a year have better survival figures for their patients. Just as we need a team approach to screening, so we need a team approach to treatment. No woman should be referred to a general surgeon working in isolation. That is why the establishment of specialist breast units with defined minimum standards and service requirements is necessary. National standards need to be laid down, nowhere more so than in radiotherapy and related areas.
The hon. Member for Colchester, South and Maldon spoke of the evidence given by RAGE. For some women, the treatment has been horrendous, leaving them either in pain or disabled. For some of them treatment can be worse than the disease. So the same quality of standards as is required for the screening programme needs to be applied to radiotherapy.
In this respect I should like to mention recommendations 29 and 30 of our report. The Government rejected the recommendations calling for the same service quality standards to be applied to treatment and screening, and I found that rather disappointing. The two services are wholly complementary: they involve the same training and the same commitment to specialisation. Experience gained in one sector is also gained in the other. Of course some extra staff and resources would be required; will the Minister tell us why the Government rejected these two recommendations?
I should like to return now to the role of breast care nurses, to which Conservative Members have already alluded. All the people with experience of breast cancer who spoke to us had nothing but praise for the nursing profession and for the crucial role that breast care nurses
play. Obviously the remarks that follow will be from a male perspective, but many women who have been told they have breast cancer face not only the fear of the physical consequences--there is deep psychological trauma about the possibly tragic outcome of the disease-- but a disease which attacks their identity as women. They feel that their femininity and their feelings about their sexuality are under attack. The women in this category to whom I have spoken have all said that the one person they could talk the matter over with was the breast care nurse. As one of the witnesses who came before the Select Committee said, "If nurses can communicate with us, why can't doctors?" So there is much that still needs to be done in terms of training the doctors.
Gwyneth Vorhaus described for us the time when she was first diagnosed as having breast cancer:
It is important to listen to what women have to say. I do not want to interfere in the debate about high-dose chemotherapy and stem cell rescue. Certainly, we heard Gwyneth Vorhaus say that she felt the treatment was right for her. We should do some random clinical trials to assess the value of high-dose chemotherapy. Most of us on the Committee felt that here was a woman who had exercised choice and weighed up the risks. She said that if nothing had been done she would have died. She was a mother of young children, so she felt that if anything could be done to extend her life by a couple of years, it should be done. For many of us that summed up the issue behind this disease.
My hon. Friend the Member for Halifax (Mrs. Mahon) said in another debate on this subject:
When looking for the resources needed to build an effective screening and treatment programme we should always remember the 4,000 lost lives each year, and the costs of not saving them.
"will be purchasing services for monitoring their own purchasing".
I hope that the Minister will outline in his reply the role of regional offices and regional directors of public health in selecting the lead purchasers, and also the monitoring role of the national co-ordinator. That must be kept under review and I hope that the Select Committee will consider the issue once the new arrangements are up and running next year.
"costly trawling of a limited asymptomatic public group . . . creating huge . . . psychological and physical morbidity".
That is why it is important that we do our best to eliminate the false negatives and positives.
"I was left undressed in a cubicle for over two hours at the general surgeon's clinic. I finally wandered out into a room where a junior doctor was sitting looking at an X ray and I discovered that it was my X ray. I had previously been told I probably had fibro adenoma, so I had no reason to prepare myself or bring a friend. The doctor looked very embarrassed. He turned his back on me and started muttering about 'microcalcifications and suspicious lesions'. I had to ask him to turn around and look at me. I said, 'Are you trying to tell me I've got cancer?' He still could not use the word, but his body language told me something was wrong. I believe I went into deep shock at that moment, but I was left to wander off for an explanation to my GP."
Perhaps that was an isolated incident, but as the hon. Member for Colchester, South and Maldon said, it is one incident too many. Other women's experiences may not have been as graphic, but witness after witness has described the insensitive manner in which her first diagnosis was given her. Meanwhile everyone praises the commitment and the work of the nurses.
"it is important not to view breast cancer as just a woman's disease because it brings devastation and grief to families affected by a sufferer's early death."--[Official Report, 15 February 1995; Vol. 254, c. 945.]
Women with breast cancer are daughters, mothers, wives, partners, lovers. They have caring responsibilities, and their early and often unnecessary deaths devastate whole families; and the cost to communities is enormous.
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