Chairman: Appearing before the Committee is Mr. Barry Dempsey, Chief Executive, Irish Cancer Society and Ms Joan Kelly, Professional Education Manager, Irish Cancer Society. The Cancer Society was established in 1963 and is the national cancer charity dedicated to preventing cancer, saving lives from cancer and improving the quality of life of those living with cancer through patient care, research and education. The Society relies totally on voluntary contributions and raises approximately £2.5 million annually to help fight cancer.

Members of the Committee have parliamentary privilege but this is somewhat limited for members of the delegation. However, I am sure this will not cause any difficulty.

Mr. Dempsey: Thank you, Chairman. Some of the illustrations are not as visible as we would like. Nonetheless, we will go through them and discuss them afterwards.

To put in context what the Cancer Society does, cancer as a disease is abnormal cell division. The orderly process of cell division goes out of control and cells continue to divide without any break or without impediment to form tumours. There are in excess of 200 different types of cancer. Each different variety of cancer has its own defining symptoms and its own defining treatments. Alongside cardiovascular disease, cancer is the number one cause of premature mortality in Ireland. Premature mortality we describe as death before 65 years of age. In general round terms, there are approximately 18,000 new cases of cancer diagnosed in Ireland every year. There are approximately 7,500 deaths from cancer in Ireland every year. The big picture statistic for Ireland, and for Europe generally, is that one in three people will get cancer at some stage in their life and one in four people will die from cancer.

In terms of the varieties of cancers, half of all cancers diagnosed in Ireland, and in Europe generally, are of three types. There is skin cancer, bowel cancer and breast cancer which represent 50 per cent of all the new cases. The treatment outcome for skin cancer is very positive. In any one year, on average there would be approximately 7,000 cases of skin cancer and the average number of deaths from this cancer would be approximately 36. This is a very strong positive treatment outcome. The mortality rate for breast cancer is in excess of 30 per cent. Looking at it from a positive perspective, approximately 65 per cent plus of breast cancer patients have a five year plus survival rate. We would consider this to be total survivorship. Bowel cancer moves down the scale. This would have a mortality rate of approximately 50 per cent. About one in two patients who contract bowel cancer will die from it. These three cancers account for half of all cases and at the other extreme of the scale is lung cancer. Lung cancer is not by any means the largest cancer in Ireland, or in Europe generally. It accounts for approximately 8 per cent of cases, but of that 8 per cent the treatment outcome is very poor. There is in excess of 90 per cent mortality rate. Of the 8 per cent of people diagnosed with lung cancer, the treatment outcome is very much at the other extreme from skin cancer and even from breast cancer. Lung cancer has a very high mortality rate.

Cancer mortality is largely based in lung cancer, colorectal cancer and prostate cancer. Most cancer deaths in males are accounted for by these three. In females most cancer deaths are accounted for in breast cancer, lung cancer and colorectal cancer. I will split the risk factors in these three big cancers for male and females into external and internal factors. The external factors we list as chemicals, radiation and virus. The internal factors are hormone issues, immune conditions and inherited factors. Cancer is a very multifactorial disease. Factors might predispose somebody in a certain situation to becoming ill but this does not necessarily mean that person will become ill. It is a very multi-factorial disease. Certain factors might predispose one to illness, but that does not necessarily mean that one will become ill. A broad range of factors come into play in individual cases. The fact that a factor is in place does not necessarily indicate that somebody will become ill from cancer, but it has been found that there are factors which might associate with other factors to lead to cancer.

Let us look at the risk factors for some of the common cancers in more detail. The specific risk factors for breast cancer are hormone activity, a family history of breast cancer, and a first pregnancy after the age of 30. For colorectal cancer the risk factors are colorectal polyps, the classically described high fat/low fibre diet, and a familial polyposis coli, the presence of which, again, seems to be associated with the incidence of colorectal cancer. Cancer of the cervix is another common cancer for which the risk factors are the human papilloma virus, multiple sex partners, smoking and the herpes simplex virus, so there are good virus indicators there as to relationship to cancer of the cervix.

I will now refer to the factors for the big cancers. For lung cancer, without any argument, the number one risk factor is cigarette smoking, both active and passive. Asbestos is another risk factor which is also linked to lung cancer.

Let me finish up our introduction to the risk factors by talking about lung cancer, which accounts for more than 20 per cent of cancer deaths. We think of a cigarette as containing tar and nicotine, and there has been much discussion about tar and nicotine in cigarettes. I will briefly list all the chemicals that are in a cigarette when it is ignited and when it is being smoked - all the items that are indicated with a star are identified carcinogens. They include hydrogen cyanide, thaluidine, ammonia, urethane, tulluine, arsenic, dibensocridine, phenylbutane, polonium and DDT. On the other side we have paint stripper, naphilbiumine, which is another carcinogen, methanol, pyrene, nicotine, cadmium and carbon monoxide. I have already mentioned that in terms of external factors which indicate a predisposition to cancer, chemicals are the number one external factor. The chemicals I listed are inhaled in a lighted cigarette. Of all the chemicals indicated there are seven known carcinogens in addition to what we term tar and nicotine.

The Irish Cancer Society is the national voluntary agency dedicated to improving the lives of people living with cancer. It is dedicated to reducing cancer mortality and to promoting cancer prevention. It was founded in 1963 and is a registered charity. The society's modus operandi for delivering on its objectives are, first, through direct patient care, second, through research, and third, through education of both the public and professionals. Direct patient care from the Irish Cancer Society is delivered through five different routes. It is delivered first through the home care service. The home care service is given by specialist cancer nurses skilled in the care of patients with advanced cancer. It is delivered in 25 counties throughout Ireland and is arranged through local health boards and hospice groups. It is also knows as daffodil nursing. At any one time there are 38 nurses in the 25 counties delivering the home care service. It is delivered free and is part of the Irish Cancer Society's direct patient care.

The second way in which direct patient care is delivered is through the night nursing service. The night nursing service is for seriously ill cancer patients. Needy patients and their families can avail of up to five nights free nursing through the Irish Cancer Society in any county in the country.

The third and newest way in which direct patient care is delivered is through oncology liaison nursing. Oncology liaison nursing is an initiative to provide professional psychological and caring support for cancer patients, their families, and their core peer group. It is a specialist nursing service which does not necessarily get directly involved in delivering chemotherapy, or in the actual medical care, treatment and therapeutic care of the patient. It brings with it all the skills and abilities, but it actually delivers to the patient an understanding of what is happening, an understanding of the treatment path, and it provides the link between the consultant, the general practitioner and the patient. Currently, there are six oncology liaison nurses working in Ireland. The service was only introduced a couple of years ago, and the Irish Cancer Society is ambitious in terms of how to roll out the service throughout the country. Of the six oncology liaison nurses, there are three in Dublin, one in Cork, one in Galway, but we have just funded a second post for Merlin Park Hospital in Galway and that will make up the six oncology liaison nurses.

The fourth way in which direct patient care is delivered is through the freephone help line. The Irish Cancer Society's freephone help line can be dialled free from any telephone in the country and it is staffed entirely by specialist cancer nurses. It is not an amateur or voluntary service - all the calls are taken by specialist cancer nurses. They give information, advice and ideas as to referral, and provide a constant daily resource for a cancer patient or the patient's family and everybody around them in terms of answering key questions as to how they are doing with their illness. The fifth way in which direct patient care is delivered is through practical help. The Irish Cancer Society gives financial assistance to needy cancer patients and their families. Those five services make up the direct patient care within the Irish Cancer Society.

The second area of activity in the Irish Cancer Society is in research. The Irish Cancer Society is the largest single voluntary funder of cancer research in Ireland. It has an investment in virtually every significant cancer research programme which is under way in Ireland. In the 20 years that the Irish Cancer Society has been investing in research, it has spent £3.1 million on cancer research in Ireland. As a newcomer to the sector, let me put that into context and compare it to other research and development budgets. The national strategy's recommendation for three year's support for cancer research is £200,000. That is how the figures stack up, and the Irish Cancer Society has put in £3.1 million of voluntary funds over the last 20 years.

I apologise that this is not very visible to the Committee, but I have just received an outline of what we are doing in the current year. If anybody would like a copy, we will be happy to arrange to supply them after the meeting. There is a listing of new grants and locations, and a listing of doctors and professors who are carrying out the research, and the subject titles are noted on the right hand side. I will go down to number three because I can actually say it. Protein kinase C and colon cancer is a particular project being undertaken in St. James's Hospital with Dr. Kelleher and Dr. Long. I have a summary of the new projects we are supporting this year. There is a listing of projects which are carry-overs from previous years that we are continuing to support. Dr. Armstrong's project about three dimensional conformal radiation for lung cancer and other projects are identified. There are projects under way in Cork, Galway and other locations which the Irish Cancer Society is supporting.

In terms of the Irish Cancer Society's research activities, even eminent doctors on the boards of the society and on the medical board would agree that great therapeutic and curative advances have resulted from the Irish Cancer Society's investment in research over the past 20 years, but it is realistic to say that after 20 years we cannot cure cancer, that we have not made that advance. There are other very important advances. The important advances resulting from research carried out include improved diagnostic techniques. There is progress in terms of the diagnostic techniques that are used and in relation to new techniques and their use. The second area of research where we make progress is in reducing side effects particularly from cytotoxic treatments which we know as chemotherapy. The third area of progress in terms of the outcome of research carried out here in Ireland is in keeping the medical community contemporary. As to the third outcome, it is an important outcome that there is some support for research in Ireland and that research projects are undertaken and carried out here because they provide a very important mechanism and focus for the medical community to continue to remain contemporary with what is happening with peers globally and in Europe particularly. Those are the three outcomes of cancer research in Ireland that we would point to.

The third area of activity is education of both the public and professionals. In public education, through public campaigns and initiatives targeting schools, the workplace and community groups, the Irish Cancer Society delivers a year round programme of education about what cancer is, what factors predispose somebody to getting cancer and about general community issues relating to cancer. The society produces a wide range of publications on the cancer issue. The publications are for the population at large. There are publications specifically for patients and families affected, and there are also publications for the medical community. The Committee will see from the few items that have been distributed in the pack that it includes some very general health promotion publications. There is a more specific publication which is just an example of the amount of detail the Cancer Society goes into in its work. This is a publication for parents whose children have been found to have cancer and answers a wide range of questions that would occur to a parent. Because being involved in cancer is such a lonely experience, it is terrific to have one booklet which is a source of information on where to go to find answers about incremental things that might happen. That is the range of activity in public education.

The society also has a programme of professional education throughout the year which is delivered by our professional education manager, Joan Kelly. This includes lectures, study days, a five day programme for general nurses in cancer specialist nursing, and also - the main input to professional education - the one significant course for specialist cancer nursing in Ireland, the diploma in oncological nursing delivered through the School of Nursing in UCD. That is a programme that the Irish Cancer Society was involved in originating and which it continues to fund. As a result of the programme in the School of Nursing in UCD, at any one time there are 40 students studying to become specialist cancer nurses, and there are more than 100 specialist cancer nurses working in hospitals and communities throughout Ireland.

In terms of funding, the Irish Cancer Society is funded entirely by voluntary donations. The society spends 45 per cent of its funds on direct patient care, 16 per cent on education, 10 per cent on research, 20 per cent on fund-raising, 6 per cent on administration, and 2 per cent on advertising and promotion. The bulk of the spending is on direct patient care, education and research. In terms of how the Cancer Society raises funds, daffodil day proceeds make up 29 per cent of the funds. In addition there are weekly fund-raising activities - every week somewhere in the country the society engages in some kind of fund-raising activity. The proceeds of those activities make up 67 per cent of our income. We have donor designated contributions which are a very small part of what we do. Such donations are obtained when somebody wants to make a contribution to the society but specifies conditions as to how that contribution is applied. Currently that makes up just 1 per cent of our income. Investment income is shown at 3 per cent. That 3 per cent from investment income relates to performance in the previous five years. We would expect the investment income to drop closer to 1 per cent of the society's income in terms of interest rates and secure investments.

The last function and activity of the cancer society is that at a different level we get involved in framing support groups. We do not manage, nor do we own support groups, but we do provide a framework for them. We provide administration for support groups and we provide a location. We provide guidance and professional training for groups of either patients, parents, or community groups, people who are very deeply involved in cancer and former patients. They form groups to help to look after each other, and the society has a very active role in providing a framework in which they can operate.

The Irish Cancer Society recognises that it has a role of advocacy of behalf of its patient population which includes patients who are either vulnerable individuals or very small groups with no real cohesive core. Let me give two brief examples of the type of advocacy in question. Benefits for cancer patients include the domiciliary care allowance and the long-term illness benefit. Domiciliary care allowance is a hangover from the handicapped children's allowance. There are circumstances where it would be appropriate to establish it as a handicapped children's allowance but which really obviate it from being relevant to infants and children who have cancer. The two conditions are that a child has to be over two years of age and has to have been ill for more than six months before they and their families can benefit from the domiciliary care allowance. That prevents many of the 100 infants and children who get cancer every year in Ireland from being able to avail of that allowance. We would have a role of advocacy in that regard. We have a similar role in regard to the long-term illness benefit. The only cancer-related illness which is eligible for that is acute leukaemia, but medically, acute leukaemia is not a long-term illness. We and the cancer society hope that at some point other cancers might be deemed eligible for benefits that are available to needy patients who have long-term illness.

Chairman: Thank you for a very erudite presentation. We will take the opportunity of allowing the members to ask questions. Let me lead off by saying that the number of men who spoke at the EC is about 43 per cent as against 28 per cent of women over the past few years. It is now suggested that the gap is narrowing and that in a number of years there will be more women speakers than men. In terms of your education role, what are your views on health promotion? I am particularly interested in the co-ordination of the promotion between the Department of Health, the Irish Cancer Society and other agencies. Is it your view that we should be targeting young women in the context of smoking?

Mr. B. Dempsey: I will answer the second question first. It is our view that we should be targeting young women in regard to smoking. There is evidence that there is a much stronger uptake of smoking currently among teenage women than among any other population group. We would be very concerned about that. Any of our medical colleagues within the cancer society or any eminent oncologist in Ireland generally will not necessarily talk about trying to prevent people from smoking or encouraging them to give up smoking. The medical community throws its hands up in despair at the likelihood of achieving significant drops in smoking other than by using instruments like the price instrument in which we have a great deal of faith and which we feel could be used very effectively. Our real emphasis would be on stopping people joining the chain of smokers, on encouraging them not to take up smoking, not to become addicted, because smoking is not a habit but an addiction, and it is deliberately structured as an addiction. We would be concerned that teenage girls particularly are smoking more for reasons of peer group pressure, for reasons if self-esteem and from a sense that smoking is related to weight factors.

We are concerned that teenage girls in particular are smoking more for reasons of peer group pressure, self esteem, weight factors and body image. We would be concerned to find ways of targeting teenagers in general, and teenage girls in particular, to encourage them not to become smokers.

That is our answer to the second question. If we link that back to the first question, the resources required to effectively package and deliver a message to teenagers in relation to smoking and tobacco use are outside the scope of the Irish Cancer Society. They are outside the scope of all of the voluntary agencies who might be concerned joined together. My understanding is that the Health Promotion Unit has £3 million to spend on all of its activities in any one year. One nicotine replacement product in Ireland has a promotional budget of £500,000. That is seen as what is required to deliver the message effectively to the population for one brand of nicotine replacement. If you relate that to the HPUs total budget of £3 million, the HPU has a very difficult goal to achieve in delivering the whole range of messages it has across the health promotional spectrum in terms of the resources and the budget which it has. Nonetheless, it does work very effectively in some areas. It will get an exponential effect from its budget if there is a closer link between the HPU and the individual health boards. If messages which are packaged and delivered in co-operation with voluntary groups like the Irish Cancer Society can somehow be followed through and linked regionally through the health boards, and there can be a much stronger follow up in regional health boards, an exponential effect will be felt from that budget.

Chairman: You are saying the approach is not co-ordinated in effect. If you look at the statistics you are a cancer society with a preventative group and yet the percentage of young girls smoking continues to rise. That smacks of failure. Are you saying there is not the type and level of co-ordination required between the various groups interested in this area? How much money is there for promotion between the voluntary and statutory agencies in this State? Are we spending that money to best effect?

Mr. Dempsey: The Irish Cancer Society spends approximately £150,000 a year in this area. The other main player would be the Irish Heart Foundation. We are not aware of the Irish Heart Foundation's spend in this area but we would assume it is equivalent as we undertake a number of projects as joint ventures and we tend to match each other in the work we do in schools and work places.

We also have joint ventures with the Department of Health and Children. There is a venture called Smoke Busters, a primary school led initiative which is currently being undertaken by 90 primary schools in the Eastern Health Board region. It serves to deliver a non-smoking, anti-tobacco message to primary schools. The funding for that is made up of small bites from different Departments such as Health and Children, Education and Science, the Irish Cancer Society and the Irish Heart Foundation. The Irish Cancer Society contribution would be significantly larger in a programme like that than the Department of Education and Science's contribution, even though it is a school project. Currently the tobacco programme which is envisaged from the Department of Health and Children is being budgeted at £240,000. In any one year if we have £240,000 from the Department of Health and Children and £150,000 each from the two main voluntary players, this brings us up to £540,000, but the two voluntary bodies are spending as much, in terms of their direct spend, as the HPU would be spending in the area.

Deputy Keaveney: I welcome you both here today. This is an interesting topic as there are very few families which have not been or will not be touched by cancer at the moment. It is a good to see people have gone beyond the "big C" and are willing to talk about it.

Everywhere people believe their area has the highest incidence of cancer. This is a point which is always brought to me, people say they are the worst so why can it not be found out why they are worse than everyone else. Is there much research going on in this area? I know certain health boards gather information on a district basis. Is that pursued at local level in terms of environment or other factors which might have an impact? In the Foyle area people have different concepts of the problem as every other household has a problem with cancer. Is there any scope for science research students to examine pilot areas as a topic and look at the factors behind the deaths in certain areas? I come across this often as a public representative.

I complement your organisation and the work which it has done but I would also mention the great work being done by the hospice movement. What links do you have with the hospice movement on both sides of the border and what North-South links do you have? Is your association on a 32 county basis?

If you live in Donegal and have a cancer patient in the family, the costs of travelling to Dublin can be phenomenal. I am glad to see there is some help from the association where there is great need. We could help to push the idea of the domiciliary care allowance and the long term illness allowance, but is there anything you see as positive within the national cancer strategy? It is a relatively new strategy.

Ms Kelly: The incidence of cancer in this country, until 1994, was counted in Counties Cork and Kerry because the Southern Tumour Registry counted that area. It counted the incidence in those counties and speculated them for the rest of the State. I travel throughout the State with the education programmes for nurses and whether I am in Donegal or Kerry, they tell me that they have many cancer cases. Since 1994, however, the National Tumour Registry has been formed and it is now co-ordinating the counting of all cancers and cancer deaths. We have one report form the National Tumour Registry and when we have more of those as the years go on we will be able to build a better picture of the true situation. We do not know the situation based on one year's evidence. It can be stated that in relation to the one year's evidence, the eastern sea board and the Dublin area seem to have a higher incidence of all cancers in general. It is early to comment too much on those figures.

On the scale of things it is less important to examine local factors than to deal with the smoking issue. It is head and shoulders above everything else. Communities are worried about this and projects should be carried out to allay such fears. However, there is not one factor which is more significant than smoking, diet or the sun, although the latter does not account for many cancer deaths. It would be a good idea to embark on such projects when we are aware of such pockets of cancer. It will be less significant than the smoking issue.

With regard to the hospice in County Donegal, there are well established links between Foyle hospice in Derry and County Donegal. Dr. McGinley, the director of the Foyle hospice, travels to County Donegal as the palliative care specialist. The county is serviced in terms of palliative care by Foyle hospice. There is a nurse based in Letterkenny who liaises with him and who visits the county. With regard to other Border counties such links are not established with, for example, Belfast. There are home care nurses based in Dundalk, Drogheda, Cavan, Monaghan and Sligo but their focus is south of the Border. However, Donegal is a co-operative effort.

Senator Glynn: The link between smoking, especially passive smoking, and cancer caught my interest. Would the invitees agree that smoking in public places should be banned? Cigarette advertising in the media should be banned because it glorifies the habit. Would they agree that many people in their fifties or sixties who did smoke have now stopped and the main smoking population is in a younger age bracket? Is it the case, as they pointed out, that there is a higher incidence of cancer on the eastern seaboard? Does that not put the focus on Sellafield and its effects on emissions into the atmosphere? That is my view, although I have no scientific evidence to back it up. However, I think it is more than a coincidence.

Is there any evidence to suggest that foods grown with artificial fertilisers carry a greater risk factor for cancer than food grown organically? Is there any truth in the view that the food additives known as the E numbers are also a contributory factor?

With regard to the freephone and the counselling, does it provide also cover the dependants of cancer sufferers? They are the ones who must carry on when the cancer sufferer passes away. I compliment our invitees for the great work they do.

Ms Kelly: It is hard to get good evidence on food and specific dietary items in terms of their effect on influencing cancer. The research to date has examined bigger issues in terms of high fibre or low fat diets in Africa, for example, where there are low rates of colon cancer. There is also a low incidence of breast or colon cancers in Japan but Japanese people who move to the US have within one generation the same incidence as the Americans. Based on such evidence we conclude that diet has a great influence in cancer development.

With regard to additives and pesticides, the message from Europe is that to prevent colon cancer people are encouraged to eat four or more portions of fruit and vegetables per day. Following such a recommendation means that by necessity one cuts down the amount of fat in the diet. If one examines a cake it may have an expiry date more than a year away so they must be full of preservatives. Reducing the numbers of preservatives and processed foods we eat, including more fresh fruit and vegetables in our diet and reducing the amount of meat we eat can help to reduce the risk of colon cancer.

Mr. Dempsey: We are cautious of describing what we do as "counselling" in that, although it would be our preferred assistance, we do not say that we give counselling. We give referral, advice and information. Cancer is an individual and lonely situation and we would be careful at distance not to lead a patient or their peer group, but we try to give as much support as possible without crossing the counselling threshold. We provide information, support and advice for everyone to do with the cancer patient and for the public at large. On the freephone yesterday I took a call from a mother who wanted to know how to tell a nine year old that her father was not going to live. I took another call from the partner of a person diagnosed with a malignant melanoma who came back from hospital without knowing anything about a malignant melanoma or the interferon treatment prescribed. Such are the gaps that we can fill. However, we will respond to any call for any assistance.

From an epidemiology perspective, proving or disproving the Sellafield connection is obviously controversial and difficult. The Cancer Society would be happy to get involved in such an issue but it is such a big issue that it is a matter of State. Significant work has been done on it in the past but it is an extremely difficult epidemiological issue. There is nothing we can satisfactorily add to what has been said about it already.

The cancer society would be in favour of banning smoking in public places. We have an association with a lobby group, ASH Ireland, and we know that it is lobbying for more effective use of the price instrument. There is no reason why cigarettes cannot be £5 for a packet of 20. There is empirical evidence to show that in other countries in Europe and on the periphery on Europe where this instrument has been used cigarette smoking and its uptake have fallen off significantly. We would be in favour of such measures and we would be in favour of banning smoking in public places.

You asked about Sellafield and the cancer strategy. Up until this year the cancer society advertised to consider basic or clinical research projects. However, this year for the first year we have significantly increased our research fund. In our advertisements we have said we are prepared to support not only purely clinical or basic laboratory research projects but also projects relating to epidemiology; social oncology, which deals with how cancer occurs in communities and affects them; and psycho oncology, which deals with how well patients are when they are diagnosed with cancer and the support and care they require. We have opened up the type and sophistication of projects we are happy to look at from a research point of view. There is another cancer strategy issue that feeds from that but I will not take up the time of the committee with it now.

Senator Jackman: Thank you for the excellent presentations. On early detection and screening, we are much lower than Greece, with both countries being at the bottom of the European barometer. Is this due to a lack of sufficient detection and screening programmes or because women do not avail of these services, or a combination of both? Have the detection-screening programmes put in place in recent years led to an improvement? It is frightening that we are still at the bottom of the European barometer, particularly as so many cancers in women can be cured if there are detected early. This is as frightening as the level of smoking among young children, some of whom start smoking as early as 11 or 12 years and are addicted by the age of 14 or 15. I am digressing slightly but I want to make the point that despite the heavy penalties imposed by schools there is no reduction in the numbers smoking. I am concerned about our position on the European barometer in relation to detection and screening.

Ms Kelly: We do not have a national screening programme for cancer but we are about to embark on a national breast cancer screening programme. The type of screening we have now is called "opportunistic" where some women, of their own volition, are screened for cancer, particularly breast or cervical cancer. Not all cancers are amenable to screening, and unfortunately lung cancer falls into this category. There are many WHO guidelines to be adhered to long before starting a screening programme. A national breast cancer screening programme will hopefully commence this year. When I ask when it will start I am told September.

Under the pilot Eccles Project based in the Mater Hospital women from counties Monaghan and Cavan and north inner-city Dublin - it wanted an urban-country mix - were screened. It was found to be worthwhile to screen women between the ages of 50 and 65 by mammography. Under the first phase of the breast cancer screening project women in this age group will be invited to attend and if they do not show up they will be reinvited. There were problems in regard to a population database but these have been sorted out. The first phase of the project will involve the Eastern Health Board, the North Eastern Health Board and the Midland Health Board.

Cervical cancer screening is also mentioned in the cancer strategy and work by the Department of Health and Children in this area is ongoing. It is easier and cheaper to screen for cervical cancer than breast cancer but the age group for screening is wider, between 25 and 60 years. The national screening project for cervical cancer will probably start in the Mid-Western Health Board area.

It is very difficult to embark on a national screening programme because of the number of quality assurance issues which need to be addressed. One must remember that healthy people are being asked to come forward for screening and it is important to ensure one does not end up in a false-positive or false-negative situation. Some communities may already have fears in this regard and if the job is not done well then you may be cutting off your nose to spite your face. That is going to be a difficulty.

Deputy Shatter: I thank the members of the society for their presentation. I was a few minutes late but I have read all the material we received in advance of the meeting. I would like to raise a number of issues. I apologise if one or two of them are repetitious but they are crucially important.

I am firmly of the view that smoking by young children and teenagers has much to do with peer pressure and self-image. Children can be brought up to regard smoking as a particularly obnoxious and unpleasant habit if an anti-smoking ethos is not only a part of their life but also a part of their education. A few advertisements on television do not have a huge amount of influence. Only a few of us who watched television in the last couple of days will remember the advertisements that interrupted the programmes we were watching. Advertising on television has a limited impact on people. If we imbue children of five, six, seven and eight years with the view that smoking is an unpleasant habit by the time they are teenagers they are so anti-smoking they do not regard it as an option. We have not yet approached the problem in that way. We tend to raise the issue with children when they are ten, 11, 12 and 13 years. However, it is easier to condition an anti-smoking attitude in children at a younger age.

Does the problem arise because the issue falls between two Departments? With all due respect to them, while the health promotion units of the Department of Health and Children and the Department of Education and Science feel it desirable and somewhat politically correct to allocate a small sum of money each year to campaigns in which the society is involved, this is not seriously treated as an education issue. If it was treated as an education for life issue which impacted at primary school level at a young age it would create the conditioning which would allow young people to ignore peer pressure. Over a period of years the peer pressure could end up being in the opposite direction, for example, an anti-smoking peer pressure. Am I correct in saying we have not yet started to approach the matter in this way and we are doing too little too late?

I agree that we should ban smoking in public places and all tobacco advertising. The European Union is moving towards a ban on advertising. What can we do to ban smoking in all public places? Despite the large number of people who smoke, if the Minister for Health and Children or a sufficient number of Deputies had the courage to support legislation in this area it would have broad support within the community. At this stage it is more an issue of political courage than an issue of lobbying.

You made the interesting comment that research is one aspect and that medical practitioners and oncologists practising in this area must be up to date on contemporary developments. Are you satisfied they are up to date on contemporary developments in other countries in the context of cancer treatment? Is it the case that perhaps we do not always provide the most contemporary treatment because of the constraint on resources or because of expenditure difficulties? Is it the case that those in the private health sector, members of BUPA or VHI, are more likely to be given the most contemporary treatment for cancer than those in the public sector? Is there a problem with waiting lists in this area? I know of cases, for example, where people have been diagnosed as having what appears to be a malignant lump on their breast and in the context of access to private health care the person would be admitted to hospital within 24 to 48 hours, with the necessary medical intervention, whereas in the context of public care, because a judgment is made that there is not an immediate risk of the cancer spreading, the person might wait two or three months before being admitted to hospital. Is that placing lives at risk?

The other issue arising out of medical treatment - you raised it with the example you gave of a person with whom you had to deal recently on the telephone - is whether doctors dealing with this issue, in many instances extremely well, on a daily basis could benefit from social training on how to communicate with patients. Regardless of how elevated doctors are in their profession, it is my perception - I may be wrong - that, despite medical commitment to and expertise in this area, the difficulty on occasion is that, while each patient has similar problems, because doctors work under pressure the human element and need to spend time explaining the implications of a cancer diagnosis is not always met. That adds to the difficulties of both the person who is diagnosed and the immediate family in coming to terms with the implications of the diagnosis. From your society's perspective, should more be done within the medical profession in that regard?

I am firmly of the view that a national screening programme is needed, particularly in the context of breast and cervical cancer, and we now have the medical technology to extend that to prostrate cancer. The programme that will be started next September will not be a full national programme with a pilot dimension to it - it is semantically described differently. Are other countries dealing with this matter better than we are? You suggested they are in some instances and perhaps you will expand on that.

My final point is a general comment. For many years I have had particularly strong views on tobacco and cigarette smoking, probably because my parents subjected me to the type of conditioning to which I would like to see many people at home and in schools subjected. There is an extraordinary irony in that we conduct a war against young people who smoke occasional cannabis, and while I would not necessarily support the smoking of cannabis and certainly would not advocate it, 6,500 people die every year in this country from smoking-related illnesses, the major ones being lung cancer and heart disease. If Sir Francis Drake landed on our shores tomorrow morning announcing the arrival of tobacco, and we all understood the implications, he would be arrested and probably sentenced to 20 years in jail. There is an extraordinary double standard here in that we tolerate tobacco companies and shopkeepers who sell cigarettes to children. We are not really serious in the war against tobacco companies. The resources and thought put into that area are inadequate and our health services have to cope with the impact of that.

If you or I went out on the streets today to sell any product that kills 6,500 people a year, we would expect to face a very lengthy jail sentence. I find it quite extraordinary, with all the scientific and medical knowledge we have in this area, with all the conclusive research results, we are still tolerant of tobacco companies, smoking in public places and the death and destruction caused by tobacco. This is an issue which, within this committee, should be considered more seriously than it has been considered to date by any Minister for Health or Department of Health. Despite the anti-smoking rhetoric that comes from the Department of Health - this is not a particular criticism of the present Minister - we have not seriously come to terms with what we need to do as a society to combat the influence of tobacco companies. On the streets of every town and city, that influence is currently much more evil than the influence of street corner cannabis sellers, which impacts on far fewer numbers of people. It is time we put this matter into perspective.

Mr. Dempsey: I will follow up on Deputy Shatter's final point and Ms Kelly will address some of the medical issues raised. In terms of cigarette smoking and our approaches to it, Commissioner Flynn has made an extraordinary achievement in bringing the advertisement ban to its current status. Although the Europeanwide advertisement ban seems to have leapt over a very high hurdle, it is not home yet. The Irish Cancer Society and other interests have written to every Irish MEP asking for their support in the conclusive vote for the advertisement ban, but so far we have had only one positive reply. We are concerned and confused about this. We have had communication from some MEPs that because they are aligned to particular European groups that are strongly influenced by Germany, they will not necessarily give a commitment that they will vote for the advertisement ban in the European Parliament. I do not know if the joint committee could recommend to individual MEPs its position.

Deputy Shatter: I formally propose a motion that this committee urges all Irish Members of the European Parliament to support the proposal put forward by Commissioner Flynn.

Chairman: I will accept a formal motion for the next joint meeting.

Deputy Shatter: I find it very disturbing that the response so far has been minimal. It may well be, in fairness to our MEPs, that they are so snowed under with work and correspondence that they intend to support the proposal but did not have time to respond. As a committee, we are entitled to take a position on this matter and I am happy that we will put this as a motion on our next agenda. Perhaps in advance of that meeting we could write to our MEPs asking them to do this committee the courtesy of furnishing us with their views.

Chairman: That is acceptable.

Ms Kelly: In regard to screening, we are about to embark on a screening programme here. Scandinavian countries do very well in terms of screening for cervical cancer. There is practically no incidence of cervical cancer in those countries. They have a very good screening programme. In Britain the interval for breast cancer screening is three years. We propose that screening take place every two years because sometimes people develop cancer in the three year interval. It is a matter of getting our own project under way and see what happens as a result of that, always paying great attention to the quality of all stages of that screening process.

The other issue raised was screening for prostate cancer about which we will hear more. Although there is no national screening programme in America, it is done through people visiting their GP or internist. It is a little more complicated to screen for such a cancer, but we are learning much more about the blood test, PSA. There have been further developments which have helped to get better results from that test. Prostate cancer will involve more than a blood test. An examination and possibly a type of ultra sound will be required. We need to pay close attention to prostate cancer which has happened in the US as a result of increasing numbers of men developing prostate cancers in their fifties, which was traditionally quite young for the development of such a cancer. We will keep a close watch on that and will be supportive of further investigation and eventually of a screening project.

The problem of communication as regards doctors and consultants exists. I, as an oncology nurse, believe it is difficult to give somebody bad news and there is no simple solution. Medical oncologists or consultants in medicine or surgery are not encouraged to embark on communication or education projects. For that reason, it depends on the individual and their affinity for that type of work. There were problems and that is the reason the cancer society brought in liaison nurses. In my experience, when a patient is with a doctor they will say "yes" to the doctor and when the doctor leaves, they will ask the nurse what he meant. Patients often tell the doctor they are well, although that is not the case.

The other matter raised related to public versus private care and waiting lists. The cancer strategy is attempting to reorganise the cancer services because if a woman with a breast lump goes to her doctor, it is likely she could have several different options of treatment and there is little co-ordination between those options. If she goes to one doctor, she will be given one option and so on. The strategy is attempting to address this and, more importantly, to put more medical oncologists into the regional health boards. We have four medical oncologists in the public sector and two appointed oncologists waiting to arrive in the summer. That is a problem which the strategy is addressing by putting at least one medical oncologist in each health boards and more in the Eastern Health Board.

The strategy has attempted to avoid situations where people must wait for a doctor's appointment if it is at all likely they might have a cancer diagnosis. It is not acceptable for women to wait two to three months with a breast lump. The cancer strategy is attempting to address that problem. Each health board has a regional director and one of their responsibilities is to have a fasttracking system for all patients and not only private ones.

Mr. Shatter: Have you come across women with lumps who are told they may need surgery but that it must wait for two to three months because there is a waiting list? That would give rise to anxiety in addition to the inherent medical dangers.

Ms Kelly: That has been the situation but I would like to think less so now. There are specialist breast clinics because it is a common cancer. We should have specialist areas as there are significantly high numbers.

Mr. Dempsey: Access to an appropriate consultant is quite rapid compared to other environments and countries in the EU. Once there is a strong indication of a diagnosis, there is quick referral to a consultant. There is a period of time in the treatment path where there is real equity between the private BUPA and VHI patient and the public patient. I arrived from commercial life to the cancer environment very recently.

I would like to follow on from Joan Kelly's reply and talk about how contemporary the treatments available in Ireland are. My understand from the leading oncologists in the country, not only in the Eastern Health Board region, is that once there is a period of diagnosis, referral from that point is quite quick. There are periods of waiting rather than a waiting list for individual surgeons or circumstances. There is relatively quick referral through to the consultant. Leading from that to the therapies and the capacity available, my experience is that if I were to be treated anywhere in Europe for a cancer related condition, I would opt to be treated in Ireland. There are remarkably skilled and able oncologists in Ireland. If one looks at them individually or collectively, one will find they have all worked in other significant centres. They have all worked in the Memorial Sloan-Kettering Cancer Centre in America or another leading edge oncological centre in Europe or America. They are constantly bringing back to Ireland the therapies and techniques they have learned there.

Last year the Irish Cancer Society supported the world lung cancer conference which was held and conducted in Ireland. It was transmitted by satellite to other centres throughout the world and the most contemporary approaches to lung cancer, diagnosis and treatment patterns were presented first in Ireland in 1997. The initiative to bring the conference here was taken by Irish oncologists and surgeons. I am confident as regards being contemporary within the medical community in that area. That situation does not permeate every county but one of the core tactics of the national cancer strategy is to fully establish and identify the centres of excellence in terms of collecting the various disciplines because, as Joan Kelly said, it is a multidisciplinary treatment approach in that it is surgery, clinical oncology, radiation and chemotherapy. Depending on the patient's doctor, they can go down a number of different paths. The strategy's tactic of focusing the best available therapies and specialists in centres rather than trying to provide all the services in every county or region makes a lot of sense. We hope that as the strategy rolls out, it will give more people access to the type of excellence we know exits within the service in Ireland.

On the communication issue, anecdotally I am aware that in the United Kingdom a well known communications expert delivered a course to consultants on communicating with patients. The course was advertised and presented to the medical community as a course in communicating with one's patient but nobody turned up. The course was repackaged and readvertised as teaching your staff how to communicate with patients and it was full. That is a true story and the expert involved was Leslie Fallowfield.

That is a reflection of how the medical community would view themselves. They are very confident in terms of how they relate to their patients. However, the patients experience is not always terrific.

Senator Jackman asked about how a patient gets onto the treatment path and why a patient might not get onto the path because of fear. We have an individual case which relates to the death of a member of a family. As it was described to us in the last couple of days, that member of the family knew they had a tumour for six months before going to a general practitioner. This is a little addressed communication issue. Our good friends and colleagues in the medical community might sometimes look to themselves as to why a patient would do that. The patient would have had access to private medical care without any difficulty and had a reasonable education, reasonable awareness and much social activity. Nonetheless, the patient knew they had a lump and has since passed away because the treatment path came too late. It was not possible to address it.

Unfortunately, that is not an uncommon situation. I hope through the work of the Cancer Society and the medical community that this will be decreasingly the case. However, it is a reality and it does not only relate to people who might not have the understanding or education to follow through in terms of finding a problem and going for a diagnosis. It relates to everybody and there is still an endemic fear. This does not only apply to older people. The case I mentioned involved a person in their forties. There is a communication issue and it relates to the point made by Senator Jackman.

Deputy Keaveney: I live on a peninsula with a population of 30,000 people. It is scary to think that everybody there would be dead in five years if the 6,000 deaths a year were concentrated in the one place. The peninsula would be wiped out.

I am very familiar with a case similar to that outlined by Mr. Dempsey where a person knew there was something wrong and probably left it too late. I mentioned the hospice movement and the North/South links and it would be remiss of me not to pay tribute to the work of

Dr. McGinley and his staff in the Foyle hospice. It is providing a phenomenal service to Donegal and Derry. I have had personal experience of the service provided by the hospice and I do not wish to let this occasion go without mentioning the invaluable work of the many staff there.

Chairman: On behalf of the members of the committee I thank the delegation for attending and for the clarity they showed in dealing with the issues raised. The delegation's presentation was excellent and the committee found it most enlightening. It has given us a sense of direction. I agree with Deputy Shatter that the issue of the health risks associated with smoking should be considered in great detail by the committee. I intend to recommend that this issue should be placed on the agenda for the next meeting of the Joint Committee. The members could then formally decide to examine the matter in depth and perhaps produce a report which could be submitted to the Dáil. The delegation by their attendance has pre-empted this move and the committee is most grateful to it.

The witnesses withdrew.

The Joint Committee adjourned at 11.15 a.m. until 11 a.m. on Thursday, 16 April 1998.