12 April 2005
An Cathaoirleach: I have also received notice from Senator Henry of the following matter:
The need for the Minister for Health and Children to initiate a screening programme for colorectal cancer, as recommended by the EU; colorectal cancer being the leading cause of mortality from cancer in Europe.
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Dr. Henry: I thank the Minister of State for attending the House this evening.
The issue of colorectal cancer was drawn to my attention by Colm Ó Móráin, professor of medicine at Trinity College Dublin and senior gastroenterologist in the Adelaide and Meath Hospital at Tallaght. Colorectal cancer poses a major public health problem. According to a recent report from the United European Gastroenterology Federation, it is the leading cause of morbidity and deaths from cancer in Europe. The incidence of colorectal cancer is steadily increasing in both males and females, and that increase is most prominent for malignancies in the sigmoid colon. In Ireland, 1,730 patients with colorectal tumours are diagnosed each year, with 925 deaths occurring.
The prognosis for patients with colorectal cancer is closely related to the clinical and pathological stage of the disease at the time of diagnosis. Unfortunately, most cases of colorectal cancer are detected at an advanced stage, and survival rates are therefore poor. Five years' survival for cancer limited to the bowel wall at the time of diagnosis approaches 90%. However, survival of five years is 35% to 60% when regional lymph nodes are involved, and less than 10% with more extensive metastatic disease. That makes it the most common cause of cancer mortality in western Europe.
The biology of colorectal cancer provides an excellent opportunity for early detection. It develops as a result of stepwise accumulation of genetic mutations. The transformation from normal mucosa to adenoma and ultimately to carcinoma appears to occur slowly over about ten to 20 years. Survival is closely related to the clinical and pathological stage of the disease diagnosis. Evidence from several studies suggests that detection and consecutive removal of pre-cancerous lesions by endoscopic polypectomy reduces the incidence of death.
Cost-effectiveness analyses have shown that screening for colorectal cancer, even in the context of imperfect compliance, significantly reduces mortality, with costs lower than or comparable with already implemented cancer-screening procedures, such as those for breast cancer. However, screening tests vary considerably in diagnostic performance, compliance rates, acceptability and cost. Randomised controls, however, in Europe and the USA have shown a decrease in death rates of between 15% and 30%.
One test widely used, which would cost less than €10,000 per life saved, as compared with €200,000 per individual for chemotherapeutic drugs, is the faecal occult blood test. Such tests detect the presence of blood or blood products in the stool. They rely on the fact that colorectal neoplasms tend to bleed more often than normal mucosa. Since some colorectal neoplasms will bleed only intermittently, testing several stool samples increases the yield. It has become standard to test three consecutive stools using guaic-based methods. Such tests have the disadvantage that they may react positively to peroxidases activity in the faeces and not solely to peroxidases activity from human haem. Faecal occult blood can also be traced using immunochemical methods. However, they are more expensive and have been criticised because of their low sensitivity.
Recently performed trials indicate that screening targeted at particular age groups significantly reduces colorectal cancer mortality. Consequently, various professional organisations have recommended the screening of asymptomatic persons to reduce the mortality rate in the population. As I said, in several European countries such screening has either been introduced or is being considered. The European Union has recommended faecal occult blood screening for colorectal cancer in men and women aged 50 to 74. It would appear to be cost-effective, and the optimum strategy cannot be determined solely by the currently available data. We must have considerable research into this area to determine the most important screening strategy. However, no such studies are in progress in Ireland. This proposal defines the start of an endeavour that will garner significant information on many aspects of screening programmes for colorectal cancer in Ireland.
Making the screening programme a reality and achieving high response and compliance rates are important. The pitfalls of earlier screening programmes should be avoided. Co-operation with existing screening programmes such as the breast-screening programme that I mentioned can greatly contribute to avoiding the pitfalls and stimulate progress in implementing a screening programme for colorectal cancer. The practicality of a screening programme depends on the detection method. Fortunately, faecal occult blood testing is simple and can be performed by the subjects at their homes without high demand.
It is essential to know those who are at risk and to be familiar with their specific education and information needs if we are to achieve high awareness of colorectal cancer and, in turn, a high level of acceptance and response to screening among clients. It is particularly important for scientific and practical reasons that we give sufficient and accurate information to all relevant and interested parties, especially if we wish to maintain and improve high rates of response and compliance.
I am sure the Minister of State will be alarmed to hear that the level of awareness in Ireland of the risks and symptoms of colorectal cancer is among the lowest in the European Union. It is conceivable that those who consider themselves to have a high risk of developing colorectal cancer are more inclined to respond and to be compliant. A high-risk assessment questionnaire has been developed to assess such expectations and considerations. Other considerations, such as general quality of life and satisfaction, might influence levels of response and compliance.
Are people satisfied to undergo regular colorectal cancer screening without a guarantee that they will be free of the cancer for life? It is possible that the awareness of risk influences the quality of one's life. Changes in one's quality of life and behaviour can change one's response to screening tests in many ways. It is hard to predict whether the availability of screening will be seen as positive or negative for certain people. We need to examine and address such issues.
I have details of how it is proposed to conduct such a pilot project and I would be delighted to submit them to the Minister of State. I hope he will mention in his response that he supports the implementation of a pilot project, especially as it is such an important issue in this country, where there is a low level of awareness of the high incidence of colorectal cancer.
Mr. B. Lenihan: I thank Senator Henry for raising this issue on the Adjournment. I welcome the opportunity to outline the Government's position on population-based colorectal screening.
The European Commission's recommendations on cancer screening were adopted by the European Council in December 2003. The Commission recommended that screening tests which have demonstrated their efficacy should be seriously considered. Any decision to implement a screening programme should be based on available professional expertise and the priority given to health care resources in each member state. The proposals recognise that ethical, legal, social, medical, organisational and economic matters have to be considered before decisions can be made on the implementation of screening programmes.
The Commission's recommendations, which encompass breast and cervical screening, suggest that consideration be given to the introduction of faecal occult blood screening for colorectal cancer in men and women between the ages of 50 and 74. Almost 60% of Irish cases of colorectal cancer occur in that age group. International randomised controlled trials have demonstrated that faecal occult blood testing reduces mortality for colorectal cancer. While such testing has been well evaluated and its benefits have been demonstrated, it has limited sensitivity and needs to be repeated every one or two years.
That a large number of people must undergo faecal occult blood testing to prevent death is a major deterrent to its use as a screening test. Although it is an effective test, its efficacy makes it unsuitable as a population screening tool. As it is just a screening test, it will not save lives without the use of colonoscopy or sigmoidoscopy to evaluate positive test results. The follow-up test for positive faecal occult blood tests remains to be clarified. Therefore, based on current evidence, general population screening for colorectal cancer is not recommended at this time. It is important that we keep our approach to colorectal screening under review, however. For example, we should consider the outcome of the well-advanced pilot screening programme in the UK.
A new national cancer strategy is being developed by the National Cancer Forum in conjunction with the Department of Health and Children. I am sure the Senator is aware that the forum comprises a multi-disciplinary group of cancer experts and representatives of voluntary and professional groups. A subgroup of the National Cancer Forum has been established to deal with generic screening. The multi-disciplinary group is reviewing all issues relating to screening and is developing the criteria under which future screening programmes will be assessed. The group has undertaken a review of international literature and evidence in respect of cancer screening. I understand that the position I have outlined is consistent with the forum's approach.
Population-based screening programmes for breast and cervical cancer have been proven to reduce mortality, with subsequent improvements in the population's survival, morbidity and quality of life. Screening aims to improve survival from cancer, limit morbidity and improve the quality of life of those who have developed cancer. The current priorities of the population screening programmes relate to the two specific cancers I have mentioned. Over €60 million has been made available to support the national breast screening programme, BreastCheck, since 2000. The programme is available to women in the 50 to 64 age group in the eastern, north-eastern and midlands areas, as well as parts of the south-eastern area. More than 165,000 screenings were conducted under the BreastCheck programme between 2000 and September 2004. Approximately 1,250 cases of breast cancer were detected during that period. Plans are under way for the extension of the screening programme to the remaining counties. Capital funding of €21 million has been approved to provide for the necessary infrastructure in that regard.
A pilot cervical screening programme commenced in October 2000 in the mid-west region. Under the pilot programme, screening is being offered free of charge to approximately 74,000 women between the ages of 25 and 60. An international expert has recently completed a report on the feasibility and implications of a national roll-out of the screening programme. The Department of Health and Children is consulting relevant professional representative and advocacy groups about the report. Approximately 230,000 cervical smear tests are conducted in this country each year. The Department of Health and Children has provided approximately €14.5 million since 2002 to enhance laboratory and colposcopy services. A further €1.1 million has been allocated to the screening programme on an ongoing basis to support the introduction of new and more effective testing in the remaining laboratories and the development of quality assurance and training programmes.
The Department's current priorities in respect of population-based screening are to complete the roll-out of BreastCheck to the remaining counties and then to consider extending the upper age limit from 65 to 69. The Department also needs to need to develop an implementation programme for cervical screening. It needs to keep international evidence on colorectal screening under review, particularly in respect of high-risk groups.
Dr. Henry: I thank the Minister of State for his reply. I ask him to consider the pilot scheme if I send him some details on it. I would like a pilot colorectal screening scheme to be pursued along the lines of the highly satisfactory cervical screening programme. We would all like the latter scheme to be extended to all parts of the country as soon as possible.
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