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Joan Ruddock (Lewisham, Deptford): I am delighted both by the opportunity to debate this subject in breast cancer awareness month and by the fact that my hon. Friend the Minister is wearing her pink ribbon.
I begin by paying tribute to the work of the breast cancer charities, which are working in partnership this monththey work extremely hard all year roundto raise awareness of the disease. Breakthrough Breast Cancer has established the Breakthrough Toby Robins Breast Cancer Research Centre, which is, of course, the United Kingdom's first centre dedicated solely to breast cancer research. The UK Breast Cancer Coalition is successfully involving hundreds of patients with direct experience of breast cancer in its advocacy work. The Breast Cancer Campaign and Breast Cancer Care work tirelessly to provide people with breast cancer with information and support.
Over the course of her lifetime, a woman's risk of developing breast cancer in this country is one in nine. Approximately 38,000 women are diagnosed with breast cancer in the UK every year. Between 200 and 250 cases of breast cancer in men are diagnosed each year, which is a tiny number by comparison, but it should not be neglected. Tragically, there are still around 1,000 deaths from breast cancer in the UK every month. Better use of breast cancer treatments in the UK has reduced deaths, but there is still a great deal to do.
This debate provides an opportunity to assess the Government's progress one year on from the publication of the national health service cancer plan. It is a chance to examine the targets in the plan and to review the action that is needed to achieve them. It is also an opportunity to consider the next steps in the Government's strategy to tackle breast cancer. Prevention is the key, so more research and a comprehensive prevention strategy are needed. Sadly, we have known for a long time that many UK breast cancer services lag behind the rest of Europe and that the quality of cancer care available often depends on where one lives. Cancer remains one of this country's biggest killers, which is why the NHS cancer plan is so vital.
There are three main targets specifically for breast cancer. First, the NHS screening programme is to be extended to all women aged 65 to 70 by 2004. That is especially welcome given that the risk of cancer increases with age. Indeed, that point has been the subject of many long campaigns involving several of those present in the Chamber. Can my hon. Friend the Minister tell us what progress has been made towards achieving that target? How many new health professionals will the NHS need to cope with the increasing numbers of women who are invited for screening? Are any of those new staff already in post, or should we expect them all to arrive in 2004?
Secondly, the plan promises a maximum one-month wait from diagnosis to treatment for breast cancer by 2001. As it is 2001, can my hon. Friend confirm that that target has been met? If not, will she explain how the Government plan to evaluate progress?
One of the aims of the breast cancer plan is, of course, to save lives. The ultimate way to achieve that is to learn how to prevent people from getting breast cancer in the first place, so greater priority must be given to research into its causes. Very few of the big killers are as poorly understood, and breast cancer is still the biggest killer of women aged between 35 and 54. The UK is among the worst countries in Europe in terms of the incidence of breast cancer. In a league table of 15 European countries, it is near the bottomonly Belgium, Ireland and Denmark have a higher rate of the disease. The Government's excellent progress on screening and treatment must be matched by a comprehensive primary prevention and evidence-based strategy.
Without identifying the causes of breast cancer, it is difficult for the Government or anyone else to advise on how to prevent it. We already know that many risk factors, including gender, age and family history, are beyond our control, but if there are other factors that we can address, we must do so, and we must first identify them. Scientists believe that breast cancer is influenced by a complex relationship between external factors associated with environment and life style, as well as genetics.
According to a recent Gallup poll commissioned by Avon, the cosmetics company, and Breakthrough Breast Cancer as part of their "Kiss goodbye to breast cancer" campaign, breast cancer is women's number one health concern. Many say that they are willing to make significant changes in their life style and environment if they can reduce their risk of developing the disease, but they need to know exactly what steps they can take. Unfortunately, however, there is little evidence that clearly identifies where such changes can be made, and all the available evidence is either insubstantial or conflicting.
If we are to get to the bottom of the causes of breast cancer and prevent its occurrence, we need more investment in research. International comparisons support the theory that breast cancer can be prevented. African and Asian women are at far lower risk than their western counterparts. The biggest difference is between women in China and Japan and those in western countries. Recent age-related figures show that the rate of breast cancer per 100,000 women is 24.3 in Japan and 26.5 in China, compared with 68.8 in England and Wales, 72.7 in Scotland and 90.7 in North America. The figures have been adjusted to include only white women, so that a proper comparison is made.
Studies on Japanese women, however, show that rates of breast cancer in those who emigrate to the United States rise and become similar to United States rates in one to two generations. That indicates that environmental factors relating to everyday activities are more important than inherited factors in the development of breast cancer. Diet could be a significant factor. Various studies have tried to establish a relationship between, for example, the consumption of fruit, vegetables and soy products, or high-fat diets, and the incidence of breast cancer. Variation in diet between east and west appears to support such theories, but we need more evidence.
We are also aware that the environment must play a part in causing the disease. Oestrogen is certainly implicated in the development of some breast cancers, yet the effects of oestrogenic compounds present in the environment are poorly understood. We need to understand not only their effects but if and how we can reduce the risk. There are many questions to be asked, and I do not expect the Minister to answer those that are really directed at the scientific community. However, we need to know whether environmental oestrogen compounds are a risk and, if so, what is their main source. What is the effect of the timing of exposure to such compounds in the womb compared with pre-pubescent exposure? Have studies looked at the correct compounds and what steps have been taken to consider the influence of compound mixtures compared with single agents?
Many commentators have implicated lindane, a chlorinated hydrocarbon poison present in our environment, in the incidence of breast cancer. I pay tribute to the work of my hon. Friend the Member for Halifax (Mrs. Mahon) who has raised the issue in the House. Most registered uses of lindane were banned in 1983, including its use as an insecticidal poison in treating timber, seed grains and livestock, and in pet and human treatments for fleas, ticks, lice and scabies. Last year, the European Union decided that lindane should be banned, and it is due to be phased out across Europe. Can my hon. Friend the Minister tell me what our Government are doing, and how quickly, to ensure that the United Kingdom will comply with the ban?
Several cancer research charities are currently engaged in breast cancer research. They are doing an excellent job but do not have the resources to undertake the large-scale life style and population studies that are desperately needed to answer questions such as those that I have posed. The fantastic work of those charities must be backed up by Government-funded research. Last year, we made a little progress when the Government said that they would match, pound for pound, the money raised by charities for cancer research. Can my hon. Friend tell us when that commitment will come on stream and how the Government will foster their partnerships with the charitable and voluntary sector?
Investment in research must be the cornerstone of any prevention strategy for breast cancer. Better smoking cessation services and the national "Five a day" programme were welcome in tackling many other cancers but will not, I believe, have a very direct impact on the incidence of breast cancer. Although extension of
There is strong public support for greater investment in research. Today, Breakthrough Breast Cancer and Avon are announcing that they have collected more than 38,000 kiss prints from the public in support of their "Kiss goodbye to breast cancer" campaign, which, as the Minister knows, urges the Government to make breast cancer prevention a priority.
I know that the Minister will join me in expressing regret for the fact that the current UK breast cancer rates equate to one women receiving a diagnosis every 15 minutes. I hope that she can give us a report on the progress of the implementation of breast cancer targets under the breast cancer plan, and that she will give us, in breast cancer awareness month, a cast-iron commitment that the Government will provide greater investment in research to tackle this devastating disease. Breast cancer is the primary health concern of women in this country.
Mr. Roger Gale (in the Chair): It is clear that many hon. Members take an interest in this subject, and I suspect that many who are not standing now will want to speak. If speeches are kept brief, it should be possible to accommodate everybody.
Mr. David Tredinnick (Bosworth): I am grateful to be called in this debate. My hon. Friend the Member for Broxbourne (Mrs. Roe) asked me to tell the Chamber that she was sorry not to be able attend today. She is currently chairing the Select Committee on Administration.
I congratulate the hon. Member for Lewisham, Deptford (Joan Ruddock) on securing this vital debate at an important time near the beginning of a new Parliament, when the Government can make an impact on the issue. I will confine my remarks to considering how the Government might enhance their strategy by introducing various therapies that are not currently available throughout the national health service. I suggest that the Minister should be developing a new perspective on cancer care, one that involves a range of therapists who are currently available in the private but not the public sector. I will give some examples of what is happening in the health service in Hammersmith, Bristol and Fulham. The Government will do themselves a favour by embracing such therapies. Not only would it enhance their capabilities, it would reduce their costs. We want to achieve greater remission for existing cases, save more lives and prevent more cases.
Since my election to the House almost 15 years ago, and over the course of four Parliaments, I have been involved in debates about different types of health care. We have about 30,000 doctors and 50,000 complementary practitioners in this country, and I have long held the belief that if a greater proportion of complementary practitioners worked in an integrated health care system, it would take pressure off doctors
Regrettably, evidence shows that since the switch from GP fundholding to the primary care group system that has taken place under this Government, the number of therapists engaged by the health service and the amount of money going to therapists from the health service have reduced because under the primary care group system a greater number of people must make decisions about what services to buy. The Government should consider that. I raised it with the Secretary of State at the most recent health questions, and umpteen times in the previous Parliament.
I have had quite a lot of direct experience of various therapies. It was my luck and privilege to travel to Japan with Rosie Daniels, director of Bristol cancer help centre, on a lecture tour some years ago. I was immensely struck by the work done at Bristol to take on patients whom other services and professionals had found it difficult to treat. I spoke to the director about the wide range of treatments employed to bring a cancer patient back from the edgeperhaps to save their life and certainly to enhance their remission. She talked not only about dietas did the hon. Member for Lewisham, Deptfordherbal treatments and acupuncture, but about t'ai chi, exercise and yoga.
Mr. Tredinnick : The hon. Gentleman is forgiven. Joking apart, I am sure that he knows that yoga has a marked effect on reducing stress. The centre also makes extensive use of therapeutic touch and people who can channel energies. I shall say more about that later.
I suggest that the Minister consider what happens in Hammersmith Hospitals NHS trust. In 1993, the British Medical Association identified a number of complementary and alternative therapies that it believed could work alongside the NHS. In 1995, Hammersmith and Charing Cross hospitals merged into one large trust, and a set of complementary and alternative therapies were available for the trust. Those services are provided for cancer patients on the health service.
Previously, many patients wanted complementary therapies such as acupuncture or healing but were frightened to tell their consultant. That unsatisfactory state of affairs exists throughout the country where there is a degree of disapproval. In Hammersmith, however, where complementary and alternative therapies are in house, everyone knows what everyone else is doing. Patients have access to massage, art therapy, relaxation, aromatherapy and reflexology. Those treatments are used to support and relax patients, help with symptom control, enhance their quality of life and, in particular, reduce the high level of anxiety, stress and tension that goes with the development of cancer.
Studies in the United States on the cost benefits of integrated complementary and conventional treatment show pretty conclusively that the Government will save money if they adopt that approach because it achieves a much better throughput of patients in a health service. As the hon. Member for Lewisham, Deptford pointed out, this country has a chronic problem with breast cancer. It is perhaps the most worrying disease for ladies of many ages. If the Government want to use the treatments to focus on a particular problem, they could hardly do better than focus on breast cancer.
Demand for the services at Hammersmith and Charing Cross hospitals is so high that they cannot offer the treatment to as many patients as they would like. That is probably why so many go to the Haven clinic in Fulham, which has developed specific breast cancer treatments. All are wonderful organisations, but the Hammersmith and Charing Cross hospitals are part of the national health service, whereas the Haven is certainly not. Many practices throughout the country offer a form of integrated health care, but much of it has to be paid for. The Minr should consider carefully how to channel more funds to those who support conventional practitionersthe hard-pressed doctorsand also take the pressure off them by bringing in complementary therapists.
There is another problem: many complementary practitioners are not allowed by law to treat specific diseases, one of which is cancer. There is wisdom in that, as it protects patients from being treated by quacks. Doctors regard it as a valuable safeguard, but there are side effects: if a complementary practitioner diagnoses cancer, he may not legally be able to tell the patient in so many words, and that is not necessarily a good thing.
I shall share with hon. Members the experiences of a friendI will call him Johnwhom I ran into the other day. I asked him how he was getting on and he told me that he was having a pretty terrible time, as he had been diagnosed as suffering from prostate cancer. He had been to see his wife's reflexologist, who had massaged his feet and said, "You seem to have a very warm prostate. I think you should get it checked." He went back a couple of weeks later for another treatment and the reflexologist said, "This is a hot prostate. You really should get it checked." When he did so, he was told that he was an emergency case and that if he was not admitted to hospital straight away he would die. Reflexology can assess not just prostate cancerthe relevant spot is near the heelbut breast cancer. If greater use were made of reflexologists, who can detect such things by feeling the feet, many problems could be stopped before they developed.
Mr. Tredinnick : The hon. Lady makes a valuable point; however, there is an extensive evidence base for almost all the therapies I have mentioned. There is some contention about the way in which certain statistics have been compiled, but there is pretty much cast-iron evidence for almost all therapies. There is certainly massive anecdotal evidence, such as the cases that I have cited. The Government should carry on with what they have done after the House of Lords Select Committee report to improve regulations, and try gradually to introduce more therapists into the health service.
Integrated practitioners usually take an holistic approach by treating the whole patient, not merely the disease. That is certainly true of Chinese medicine and acupuncture. In acupuncture, Chinese therapists adjust the meridians to get the energy to flow better through affected areas, and use herbs to strengthen the constitution. If someone's digestion is poor they try to enhance his digestive abilities so that more energyin Chinese, chican flow to the places that are a problem. In breast cancer, that could mean arresting the growth of a tumour. The same applies to homeopathy: a homeopath can treat the whole, which may assist in stopping development, or accelerating or extending remission.
The hon. Member for Lewisham, Deptford also spoke about diet. She might have mentioned the Gerson diet used at Bristol and elsewhere. An exclusion diet, it is one of many ways of reducing the threat of cancer through dieting which the Government should consider further. Meditation, prayer, yoga, stilling and exercise techniques such as t'ai chi are also valuable and, along with aromatherapy, are often used in the clinics.
I should like to finish by dealing with those who practise therapeutic touch or healing. The Confederation of Healing Organisations covers about 15 disciplines in that sector, including the National Federation of Spiritual Healers. Another body of healers who channel energy from one source or another originates from Japan. Known as reiki, it has become popular in the United Kingdom. Irrespective of whether one believes that people who channel energy through their hands, either by touching or off the body, draw from a divine source or from "universal energy", some people can undoubtedly do it. We should accept that it works. Important studies have been undertaken: for example, Matthew Manning, a well known healer, carried out extensive studies on seeds, attempting to make them germinate faster, and it is scientifically proven that he succeeded.
The healing fraternity and therapeutic touch group is particularly important in hospices. They can help a great deal by treating patients who are not going to make it. They can also help dramatically with mood swings. Someone who is trained in therapeutic touch and channelling energy might well transform, perhaps overnight, the mood of a seriously depressed patient in hospital, and the patient's condition might then
I shall not detain the Chamber further because I know that many hon. Members wish to speak. However, I ask the Minister to reflect seriously on what I have said. I passionately believe that when different practitioners work together in integrated health care, the resulting treatment will be better in terms of quality and value. The Government should acknowledge that message.
Mrs. Alice Mahon (Halifax): I am pleased that my hon. Friend the Member for Lewisham, Deptford (Joan Ruddock), who is secretary of the all-party breast cancer group, has secured this debate. With the hon. Members for Broxbourne (Mrs. Roe) and for Richmond Park (Dr. Tonge), I jointly chair the all-party group, so I know how hard my hon. Friend works.
I agree that we should pay tribute to the breast cancer charities, which are working in partnership this month to raise awareness of the disease. In particular, we should continue our support for Breakthrough Breast Cancer, the UK's first centre dedicated solely to breast cancer research. The organisation will be somewhat disappointed with me, because I lost my ribbon somewhere on the way to our debate. I also pay tribute to local events on the ground: for example, an Asda store in Halifax works every October to raise awareness of the disease in the community, with considerable success. That is a terrific initiative from a commercial enterprise.
Breast cancer treatment is sometimes seen solely in terms of surgery, chemotherapy, radiotherapy or drugs such as tamoxifen. Those are, of course, life-saving treatments, but from a patient's point of view treatment is as much about effective communication with health professionals and provision of timely and accurate information as it is about access to the most up-to-date and effective drugs. I am a big fan of the NHS, but it does not always put the needs of patients first. Ministers have been receptive to ideas about new ways in which to involve patients and improve services: one example of a good initiative is inviting patients to sit on the cancer taskforce.
We have a beautiful new hospital in Halifax, the Calderdale Royal. Its physical facilities are excellent and I have seen improvement over the years in, for example, the employment of breast care nurses. There is a local survivors group incorporating Halifax and the Calder valley, whose members have hands-on experience of the disease; it would be great if we could make more use of it. Does the Minister envisage creating more systems to tap into such expertise and develop services at a local level, perhaps by using survivors' ideas?
The National Institute for Clinical Excellence needs more resources. I know that the Minister hears that every day about some part of her Department, but NICE should be given consideration. It could be extremely effective in the future and we must not neglect it. NICE is in the process of developing breast cancer services guidance, although the original timetable for consultation on the guidance appears to have slipped.
Last week, the all-party breast cancer group held its annual general meeting and planned a programme of work for the next 12 months. We have decided to re-examine lindane, the use of which my hon. Friend the Member for Lewisham, Deptford has questioned. I also pay tribute to Unison and its women's committees, which have campaigned long and hard on the issue. I agree with the hon. Member for Bosworth that we should take diet seriously, and the all-party group has agreed to take evidence and examine diet, in particular the one known as the Japanese diet, to see whether it can be pushed on to the agenda.
I am delighted that the Government have improved and extended breast cancer screening services, but I am concerned about some older women. The Government accept that they should be invited for screening, but some women might miss out because of the time it will take for the intention to extend screening services to become a reality. Some women will miss the boat: for example, a woman who is 68 today will not be invited for screening because by 2004, when the screening target is to be met, she will have passed her 70th birthday. A group of women will miss out, despite having a higher risk of developing breast cancer than the younger women who will gain from the new screening services. Does the Minister share my concern? What could be done to ensure that the health of such women is as well looked after as that of their younger counterparts? The problem is encouraging older women to go once they have got out of the habit. In addition, we still have a lot of work to do in some of the ethnic minority communities.
I should be grateful if the Minister took those points on board. We should never forget the statistics outlined by my hon. Friend the Member for Lewisham, Deptford: 38,000 women are diagnosed with breast cancer in the UK every year, and there are about 1,000 deaths from breast cancer every month. The sufferers from this dreadful disease are the foot soldiers, and it is up to us all to carry on working for them. They are overwhelmingly women, so whole families are touched when they develop the disease. These women are sisters, wives, partners, daughters or precious friends, and we must continue to support them. I echo my hon. Friend's initial plea: we must campaign to make breast cancer prevention the absolute priority.
Dr. Andrew Murrison (Westbury): I am extremely grateful to be called to speak in this important debate. I congratulate the hon. Member for Lewisham, Deptford (Joan Ruddock) on securing a debate on the Government's approach to one of the UK's most prevalent cancers and one in which benchmarking suggests we are not doing well.
The Government took the early step of appointing a cancer tsar to oversee their strategy. The tsar has presided over the most obvious feature of their approach, which has been the apportionment of sums of moneymainly in lots of penny packets, a bit like the distribution of the Queen's Maundy money. As Professor Karol Sikora pointed out, after each announcement of cash for this or that cancer, there follows a feeding frenzy as rival institutions compete for the available funds.
The overall impression is that despite the tsar there has been precious little joined-up thinking in recent cancer strategy. The Government have consistently been warned to beware of false targets, yet there has been an unhealthy reliance on intermediate outcomeshow quickly patients get to see a specialistrather than definitive outcomes, or their chances of survival. Moreover, there is an opportunity cost to imposing crude targets: Mr. Jim Johnson, a vascular surgeon and chairman of the British Medical Association central consultants and specialists committee, told the Labour party way back in 1996 that an attack on waiting lists should be a relatively low priority because there were more important issues to be tackled, such as access to acute medical beds.
It seems likely that the Government's two-week standard has been harmful. We understand that that will now be joined by another targettime to treatment. To the extent that it is more realistic, that is to be welcomed. However, we should recognise that target-setting risks distorting clinical priorities, and that the more targets are set, the greater is the potential distortion. All of that has a profoundly demoralising effect on the health professions.
Last week The Lancet cast some doubt on the value of breast screening. Of course we must not entertain interventions without a sound evidence base, and we do people a great disservice if we stoke up unnecessary anxiety by promoting inappropriate screening. My mother experienced several distressing days while awaiting the results of such a testthat human cost of screening is rarely factored into the cost-benefit analysis. Yet we sometimes ignore strong evidence. It is likely that women over 70 are being denied operations for breast cancer, despite clear evidence from the colourfully styled "golden oldies" trial that they would benefit from such treatment.
There is evidence that highly prevalent but less appealing cancers, such as prostate and bowel cancer, are relatively poorly resourced even though their treatment may be more productive than the treatment of breast cancer. We must take a balanced view in determining priorities. Although I wear my pink ribbon gladly, I am mindful that the Government appear susceptible to high-profile pressure. I suspect that that has informed the cancer agenda, possibly to the detriment of some forms of the disease, and of health care in general.
Cancer morbidity and mortality rates are still relatively unsatisfactory in the United Kingdom, and we compare badly with similar countries. However, the fashionable expedient of blaming health workers is unhelpful; huge strides have been made since the early 1970s. I well recall the alarm that I felt as a junior doctor
Dr. Ian Gibson (Norwich, North): I wish that I had time to decimate the argument of the hon. Member for Westbury (Dr. Murrison), but I wish to concentrate on something much more positive. I congratulate my hon. Friends the Members for Lewisham, Deptford (Joan Ruddock) and for Halifax (Mrs. Mahon) on the sterling work that they have done to highlight the issue of breast cancer both inside and outside the House.
I entered Parliament not because of my political background but because I was appalled by what the Conservative Government had failed to do for health generally, particularly in the field of canceran area in which I was interested. I could not have expected what the Labour Government achieved in one year. It is absolutely amazing that we have a national health plan, a national cancer plan, and money being directed as never before towards research into treatment. We should sing the praises of those initiatives, which might not bear fruit overnight but which are certainly moves in the right direction to provide better health care for our people.
My hon. Friend the Member for Lewisham, Deptford mentioned research. This country is in the forefront of breast cancer research: recently, two of our researchers won a Nobel prize for work in the cancer arena. Oddly, their work was not on cancer cells as such, but on a yeast micro-organism. That triumph for blue-skies scientific research shows that one never knows what will be discovered when one carries out that sort of work. It is essential that we continue to fund such research, which has implications for many health problems.
Understanding of cancer has advanced by leaps and bounds, principally because of work in this country and in the United States. It was discovered in this country that a breast cancer gene runs in families. We now understand that genes might be targeted. Individuals have different genes and instead of treating organs with tumours, we can now treat individuals. Such research is primarily being carried out in this country and is funded by the Government. The prospect is that the science budget will double in the next five years.
Cancer charities are merging: I did not think that I would see the day when the Imperial Cancer Research Fund and the Cancer Research Campaign would set aside their rivalries and merge. In a Select Committee sitting, I challenged my friend Sir Paul Nursea Nobel prize winner, along with Tim Hunt and Leland Hartwell, who is an old friend from the university of Washington in Seattle. I never thought that I would get the answer from him that Omo and Daz will never mix. In fact, Omo and Daz do mixthey are the same chemical. I knew that they would mix, and I think that they knew that, too.
The rivalries have been sunk, and we have before us the great prospect that those organisations and other groups that work closely with them will combine their research to give it a British flavour, particularly research into breast cancer, where so much has been achieved. I
I support everything that has been said, and I would like to highlight some of the Government's achievements. The National Cancer Institute, for example, is not sufficiently loudly trumpeted: it is a tremendous innovation that brings together many people to co-ordinate work in this countrywork that extends all the way from involvement of patient groups to basic research. Another great move, one which was instituted by the national cancer plan, involves the national cancer networks. People who have never before worked togetherpharmacists, doctors, GPs and, now, physiotherapistsare discussing the problem of cancer in their regions and devoting their energies to developing plans. I hope that they will receive the money right at the coal face, as it were, to ensure that their prioritieswhether lindane, prevention issues or complementary medicineare addressed, or at least discussed.
The Government have initiated a tremendous spirit, not only in terms of breast cancer but right across the board, and it is a spirit from which we will all benefit. We should congratulate the Government on what they have done and sing their praises to the heights.
Sandra Gidley (Romsey): I congratulate the hon. Member for Lewisham, Deptford (Joan Ruddock) on securing the debate, which in breast cancer awareness month is timely. I always have to wait weeks and weeks before securing an Adjournment debate. I hope that she will let me into her secret.
As has been said, breast cancer strategies are an important subject. Each year, 38,000 women are diagnosed with breast cancer, and almost a third of them will die of the disease. We must do all we can to reduce those numbers. In deciding what to say, I had to cobble together sections pertinent to breast cancer from the NHS cancer plan. The easiest way of approaching the subject is to identify the separate stages of the process.
I endorse all the comments about prevention in terms of diet and alcohol. I will not repeat those points. Many women are first diagnosed with cancer at the point of screening. The NHS cancer plan proudly states that death rates from breast cancer have fallen with the introduction of national screening programmes and new and better treatments, although it does not say which measure has had the greatest effect. The plan goes on to say that among comparable countries, Britain has the most comprehensive nationwide screening programme. However, in the five-year survival rates for breast cancer, Britain lags behind Europe and is way behind survival rates in the United States. That obviously raises the question of why, if breast screening is the key factor and our screening is the most comprehensive, our survival rates are not the best.
The Minister will no doubt be aware of the work of Ole Olsen and Peter Gotzsche, which was recently published in The Lancet. The authors reviewed seven randomised trials of screening mammography and concluded that
That idea was mooted a year or so ago, and the recent paper is the result of a second look at the problem. I cannot stress enough that it reflects a single, controversial opinion and it would be irresponsible to discourage women from attending routine screening appointments solely on that basis. However, as such a large sum of money is devoted to the screening programme, it is vital that further work is undertaken to get to the truth. What is the Government's estimate of the cost-effectiveness of screening? What is the cost per case detected, per life saved and per quality-life-adjusted year?
If screening is ultimately recognised as a good measure, it is money well spent, but if there are no overall benefits, would not the money be better spent on other treatments or on an education programme? It is a sad indictment of our society that there is a gap of approximately 7.5 per cent. in the five-year breast cancer survival rates between the most affluent and the most deprived sections of our society. What are the Government doing to address that problem?
Sandra Gidley : I am afraid that the hon. Gentleman was not listening. I said that it would irresponsible to discourage women from attending breast-screening clinics, but that we need more evidence that screening has all the benefits that it is cracked up to have. Despite the screening programme, the cancer plan acknowledges that by the time they are treated, breast cancer patients in Britain are at a more advanced stage of the disease than their European counterparts.
I would like to pursue the arguments made by the hon. Member for Westbury (Dr. Murrison). The target of a two-week waiting time between referral and out-patient appointment is a cornerstone of the Government's approach. It is obvious that patients with alarming symptoms will want to be seen as quickly as possible, but what is the evidence that bringing appointments forward from two months to two weeks will improve outcomes? It is outcomes in which we are interested, not intermediate targets.
Is the waiting time more important than the time between diagnosis and treatment, which is set at a month? If I were diagnosed with breast cancer, I would not want to wait a month. Approximately 90 per cent. of women referred by GPs have non-malignant lumps, so are the Government's priorities right? Will the Minister guarantee to implement the two-week wait for diagnosis, and will she assure us that the money involved would not have been better spent reducing the waiting time between diagnosis and treatment?
Another aspect of the Government's strategy was highlighted by the hon. Member for Halifax (Mrs. Mahon). I reluctantly accept that it is appropriate for new treatments to be referred to the National Institute for Clinical Excellence, but it is becoming apparent that the process is too long and cumbersome. Women are literally dying while they wait for decisions. If NICE worked well, it would enable the Government to be fleet of foot; as it is, it is more like a rapidly developing bunion that considerably impedes delivery of the latest treatments.
I will use the story of herceptin to highlight some typical problems. The drug has been found to be effective in many cases, and some clinicians in this country prescribe it because they believe that there is enough evidence to support its use. However, we need to go back a step. Herceptin is of use in only certain types of breast cancer: an especially aggressive form of the disease, in which women over-express a protein called HER2, can now be tested for and the appropriate course of treatment identified. In the United States of America, 98 per cent. of women are tested, but in the United Kingdom only 19 per cent. are. We also compare unfavourably with Europe: 32 per cent. of the relevant group are tested in France, and 57 per cent. in Spain. Some doctors have claimed that testing is not worth while because the drug has not yet been given the go-ahead by NICE, but others are happy with the evidence.
NICE's review of herceptin started in December 2000 and a decision was expected in May. I asked in a parliamentary question when the guidance would be issued and was told that it was unlikely to appear before the end of the year. I would be grateful if the Minister could let us know the reasons for the delay. My understanding is that the review of herceptin in combination with paclitaxel is more or less complete and that a provisional decision was reached in April. Is that so? If it is, why has guidance not been issued so that women can benefit from the therapy?
It is rumoured that the delay is due to the institute examining the use of herceptin as a monotherapy, evidence for which is taking a little longer to collect. Will the Minister confirm that that is the case, and explain to those women who could benefit from the treatment the justification for delaying the guidance? Most of the women benefiting from the treatment are those who can afford private medicine; are the Government happy with that situation?
Generally, the position is improving, but we continue to lag behind our European counterparts, and the United States simply leaves us standing. My research has led me to believe that there is no cause for complacency.
Tim Loughton (East Worthing and Shoreham): I, too, congratulate the hon. Member for Lewisham, Deptford (Joan Ruddock) on securing this timely debate. I praise her and the other hon. Members who have spoken for their interest and knowledge of the subject. It has been a good debate with some excellent contributions. I also echo her congratulations to the many charities involved in cancer work, especially in respect of breast cancer, and on the great success of the "Kiss goodbye to breast cancer" campaign. I hope that it is not too late to send in my card; when I tired to get the lipstick out, it broke, and as I am not especially au fait with putting lipstick on I have not found another one, but I shall do so. The lack of a ribbon on my breast today means only that I have left mine at home.
It is important, too, to praise the many health service staff involved in cancer treatment. Enormous pressures have been placed on them to reach various targetssome of them may be misplaced, but that is another matter. We should pay tribute to the work done by nurses, doctors, radiologists and other staff.
It is vital that we consider this topic four and a half years on from the election of a Government who raised cancer treatment as a campaigning theme, and a year on from the publication of the national health service cancer plan. The hon. Member for Norwich, North (Dr. Gibson) said that the amount that had been done was breath-taking. He then reeled off a list of plans, targets and schemes that had been published. However, such things will not be the benchmark of the Government's success in tackling the causes and treating cancer in our population. What will be measured is actual output and outcomes, not the amount of paperwork, which the Government are so good at producing.
The hon. Gentleman was right to pay tribute to Dr. Timothy Hunt and Sir Paul Nurse, the Nobel prize winners of a few weeks ago. It is an irony that in this country, which is a leader in cancer research, the standards for survival do not compare with many of our European counterparts and the United States. We have
The hon. Member for Lewisham, Deptford was right to mention the importance of preventive treatments. My hon. Friend the Member for Bosworth (Mr. Tredinnick) made, as he always does, many interesting comments. I always learn something from him when he speaks about complementary medicine. It is worrying that the demise of GP fundholders has diminished the availability of complementary medicines. The interesting tale about his friend John's "hot prostate" is perhaps a good case in point, showing that there is much to be gained from liaising with complementary medicine.
The risk of developing cancer appears to be increasing and we still do not know why. There are 200,000 new cases of cancer every year. There has been something like a 30 per cent. improvement in survival rates in the past 30 years, but an alarming divergence in survival rates between different parts of the country, as well as between us and our European counterparts. The breast cancer five-year survival rate in this country is about 67 per cent., compared a figure of 80 per cent. in France. That gap is too great and I am sure that all hon. Members agree that we need to raise our game.
We can look for clues to the cause of the disparity in the availability of drugsan issued mentioned by various hon. Members. Chemotherapy drugs spending per head of population in this country works out at around 95 pence, compared with £6.24 for Germany and £3.31 for Italy. Breast cancer drugs are available to about 20 per cent. of the population affected in Europe, but only 5.9 per cent. in the United Kingdom. There is evidence that cancer patients in this country have their chemotherapy doses reduced to avoid the onset of neutropenia, which reduces protection against infection, and ensure that they do not need the expensive drugs needed to counteract that. A study by doctors at Addenbrooke's hospital showed that 32 per cent. of breast cancer patients receive sub-optimal treatment as a result of that rationing.
The hon. Member for Halifax (Mrs. Mahon)to whose vast experience and familiarity with the subject through the all-party breast cancer group I pay tributementioned NICE and postcode lottery prescribing. NICE has recommended paclitaxel and docetaxel for breast cancer at a cost of about £16 million per annum, and has recommended that they should be available to all. However, in practice, many health authorities are financially unable to provide that treatment. A study by the Campaign for Effective and Rational Treatment suggested that about 70,000 patients are being denied vital treatment, mainly because of rationing based on where people live. Wiltshire health authority has refused in the past to fund paclitaxel for ovarian cancer even though an average of 55 cases each year are reported in that county. Women
When health authorities are reorganised, will things become even worse? When even larger areas replace the health authorities that decide, as a matter of financial planning, that they cannot afford various drugs, will even more women miss out? What progress has been made in ironing out the problems of postcode prescribing? I read today that there is to be a large clinical trial of a new chemotherapy cocktail drug based on taxtere. I wonder whether that will be readily available if the trials show it to be effective. I gather that there is great hope of that.
What progress has been made with survival rates in the past few years? Last year's report, "Cancer ResearchA Fresh Look" by the Science and Technology Committee, of which the hon. Member for Norwich, North was a member, stated that the Committee was
Simply throwing money at cancer will not suffice; investment must be soundly based. We must offer a coherent system of care from the presentation of symptoms to completion of treatment. There is little point reducing the waiting time to see a consultant if there is a delay in access to diagnostic equipment or the treatment is not available on the NHS. As my hon. Friend the Member for Westbury mentioned, there is evidence that the two-week rule is proving counterproductive in many cases. Specialists must now concentrate their valuable time and resources on consultations for diagnosis, leaving them little time for the more important treatment thereafter. Barry Jackson, the president of the Royal College of Surgeons, said:
There is also the technical definition of the two-week referrals, which applies only when a GP makes a referral within 24 hours of deciding to refer. A doctor who puts a letter in the post to the consultant would not meet the 24-hour ruling. The figures are slightly artificial, but even they show that for the last quarter of 2000, 95.9 per cent. of women qualified under the two-week ruledown from 96.4 per cent. in the corresponding quarter of the previous year. The benchmark in 1997 was quite high, although I agree that it was not high enough. Some 77 per cent. of women who were diagnosed with cancer had their operations within 14 days. Will the Minister give us an update on the figure and tell us whether it is improving?
There is concern about big variations in the number of women who test positive in oestrogen receptor testing. Figures can range between 5 per cent. and 80 per cent. between different hospitals. That means not that there is a lower incidence among women in certain areas, but that the level of testing leaves a lot to be desired. What progress has been made on the important matter of raising the lowest to the standard of the highest?
The hon. Member for Halifax referred to the important issue of age discrimination, although she did not put it in quite those terms. There is evidence that women are not getting full access to treatment and, worse still, that many older women who get screened do not get treatment. The Cancer Research Campaign revealed that women over 70 are being denied operations for breast cancer, and claims that whereas younger women routinely have surgery to remove tumours, older women usually only get the drug tamoxifen. The CRC says that doctors believe that older women are too frail to be operated on successfully, although, as my hon. Friend the Member for Westbury mentioned, the CRC's "golden oldies" study gave a different view.
I do not want to be quite as alarmist as the hon. Member for Romsey (Sandra Gidley) about the effectiveness of screening. The Danish study was an isolated case, and I go along with the Imperial Cancer Research Fund's claims that women who attend regular breast screenings might reduce their risk of dying from breast cancer by more than 50 per cent. However, we need to ask questions about the cost-effectiveness of breast screening against all the other treatments further down the line that I mentioned earlier.
There is also a question about the capacity of our hospitals to deal with breast screening for older women. Last year, I visited the breast screening unit at Worthing hospital in my constituency. The team there is very hard-working, but there is only one consultant radiologist
There is a big shortage of radiographers. They do not get included enough in the publicity about terms and conditions for nurses and doctors and the technical staff behind them. The standard of radiography equipment in this country is also a problem, with many consultants refusing to accept scans from certain machines because they are out of date and the images not clear enough.
Breast cancer is an important subject, but it is not the only cancer and it should be put into the context of other cancers, including those that affect men. Some 10,000 men die of prostate cancer each year. Government spending last year on research into breast cancer supported through the Medical Research Council and the Department of Health amounted to slightly more than £9 million, whereas the figure for prostate cancer was £1.52 million. Every year, approximately 21,000 men are diagnosed with prostate cancera form of cancer that needs early diagnosis and treatment. It is excellent if we are making progress with the treatment of women with breast cancer and survival rates are increasingalthough the opening remarks of the hon. Member for Lewisham, Deptford made it clear that we have a long way to go. However, there are many other forms of cancer that affect many of our constituents and I hope that they will all be treated with a degree of seriousness and given a higher profile than many of them currently enjoy, putting them on a par with breast cancer.
The Parliamentary Under-Secretary of State for Health (Ms Hazel Blears ): I thank my hon. Friend the Member for Lewisham, Deptford (Joan Ruddock) for raising this important issue. We have all been given an opportunity to contribute to an excellent debate. All the contributions have reflected real depth of expertise in and knowledge of the issues and I have learnt a great deal. I should also like to place on the record my thanks to all the breast cancer charities for their hard work and their determination in raising the issue of breast cancer. I have had an opportunity to work with many of my hon. Friends on these issues and I am familiar with the amount of energy and commitment that the charities show in representing the interests of patients. It is also opportune that the debate takes place in breast cancer awareness month. The huge effort by the charities has been a great success this year, as in previous years.
The theme of breast cancer awareness month is myths and facts about breast cancer. Despite the fact that more women are being successfully treated than ever before and women are no longer afraid to talk about the disease, there remain several myths about the disease and it would be helpful to know the facts. One of the myths is that not many women survive breast cancer; in fact, although one in nine women will develop the disease at some point in their lives, the latest figures show that around 75 per cent. of women are alive five years after being treated for breast
It is also important to know that breast cancer is not primarily an hereditary disease. Only between 5 and 10 per cent. of breast cancers are linked to hereditary genes. It is very important that people know that. Another myth is that breast cancer screening by mammography is 100 per cent. effective. We are the first to say that that is not the case. It is the most reliable method of detecting breast cancer, but like other screening tests, it is not perfect. Women who are invited to come for breast cancer screening need to understand its potential benefits and limitations, so that they are able to make an informed choice about whether they wish to proceed.
That is relevant to the point made by my hon. Friend the Member for Halifax (Mrs. Mahon) about patients having information to enable them to become partners in their health care and make decisions with the professionals who are treating them. Information and communication are key. That is why we said in the cancer plan that all women would receive a national information leaflet on breast screening. The new leaflets will be launched at the end of the month. They are based on research and include text of the discussion with community groups and a wide range of women from diverse backgrounds. They are being overseen by the Advisory Committee on Breast Cancer Screening and the national cancer director. Information in the leaflets is evidence-based, and the advisory committee has included patients in formulating the information in those leaflets, in recognition of the importance that the Government attach to involving patients, their families and carers in developing policy.
The leaflets are a brave step in openness because they clearly outline the benefits and allow people to make a real choice. As several hon. Members said, only last week, the question of whether breast screening works came under scrutiny in a medical journal and was picked up widely by the national media. It is important to state that the majority of experts still believe that breast screening by mammography saves lives. That view is backed by all the cancer charities, and the Government share that view.
Sandra Gidley : I think that the article will probably be dismissed, but in light of the now acknowledged scientific method of rating research papers it is incumbent on us all to investigate further the allegations that it contained, especially as it repeated work done a year previously. The article picked up on the fact that some of the research highlighting the benefits of screening did not meet the criteria that would class it as high quality researchindeed, it was regarded as poor quality research by the authors.
Although not perfect, we believe that the facts about breast screening speak for themselves. Last year, 1.3 million women were screened in England through the national programme, and more than 8,000 cancers were detected. Almost half of them were small cancers that could not have been detected by hand, and more than 90 per cent. of women who have had breast cancer detected through screening are alive five years later. That is the real benefit of screening. Research has shown that breast cancer mortality fell by more than 21 per cent. between 1990 and 1998; a third of that fall was attributed to breast screening. However, the true effect of screening may be much greater, and experts believe that it is likely to be 2005 to 2010 before the full effect is seen in national mortality trends, as the benefits begin to work through.
We have confidence in our breast screening programme, which is why we are extending it. The NHS cancer plan was that by 2004 we should have extended routine invitations for breast screening to women aged up to 70. That will benefit 400,000 extra women. I am pleased to be able to tell my hon. Friend the Member for Lewisham, Deptford that we are not waiting until 2004 to start that extension of screening; we are implementing the change now. Twelve per cent. of breast cancer screening units will expand their services this year, which is well ahead of the target of 10 per cent. An additional 50,000 women will be screened this year, and we shall build on that increase in the years leading to the target date. We have already made a start, and we shall be increasing that during the next few years.
Mr. Tredinnick : Previously, the Minister said that patients and carers would help in evolving policy. She has just referred to screening. Does she recall my remarks about how reflexology can detect cancer, and does she intend to look further at complementary treatments?
My hon. Friend the Member for Lewisham, Deptford and others have mentioned the shortage of radiographers, whose role in the extension of the screening programme is vital. Although theirs is not a high-profile service, it is crucial. There are now nine pilot sites looking at new ways for radiographers to work, extending the skills of health care assistants and introducing new radiographer practitioners, to determine whether the skills mix can be broadened. There is a new programme of near patient screening that uses technology to screen patients as fast as possible, although we realise that it remains necessary to recruit extra radiologists.
As is the case throughout the NHS, there are some demarcations and boundaries in working practice that are not appropriate. The more that practitioners can extend their skills through training and education so that they are able to take on some of the work previously done by other members of their team, the more effective and efficient screening can be. We expect to have the
The NHS cancer plan set out the Government's commitment to improve cancer services across the board. It is important to recognise that time limits and targets are not plucked out of thin air without considering the outcomes. Outcomes are crucial to patients. The programme links prevention, diagnosis, treatment, care and research, and puts an extra £570 million into the process. I take issue with the hon. Member for Westbury (Dr. Murrison), who spoke of tiny little bits of funding: £570 million to improve cancer care represents significant progress.
The hon. Member for Bosworth (Mr. Tredinnick) asked about complementary therapies, which are important in palliative care and in supporting patients by dealing with their symptoms. I hope that he will be encouraged to know that his drive to integrate such services with the NHS is being taken seriously by NICE, which is to publish evidence-based guidance on supportive and palliative care. One of the issues that it will consider is the potential benefit to cancer patients of complementary services.
My hon. Friend the Member for Halifax mentioned extending screening to women aged 65 to 70, and the possibility that those aged over 70 could fall through the net. I have good news for her. Women aged over 70 will be offered free three-yearly screening on request, as women over 65 are now. Those who have been in the programme will automatically be notified of their right to that. The Government have been working with Age Concern to produce a leaflet and a video to publicise the entitlement of those aged 65 or over to breast screening.
I know that hon. Members are anxious that guidance on herceptin be published. So far as I am aware, the latest information is that, as the hon. Member for Romsey (Sandra Gidley) said, it will be published at the end of this year or early next year. I do not know of any specific reason for the delay, but I shall look into it and respond to any issues it raises.
I am delighted to say a word about men, because it is certainly not the Government's intention to ignore them. We take prostate cancer extremely seriously, and the decision has been taken to invest £6 millionnot the £1.2 million mentioned by the hon. Member for East Worthing and Shoreham (Tim Loughton)to set up two centres of excellence for research into screening for prostate cancer and its treatment. We have to find out what works and obtain an evidence base. Currently, there is not a good evidence base for screening for and treatment of prostate cancer, but we want to invest in it because we recognise that it is a huge problem for men.
GP training is crucial to detection, early diagnosis and early referral, but no single step will reduce breast cancer. There has to be an integrated approach involving diagnosis, prevention, diet, cessation of smoking, proper treatment, proper drugs, the extension of cancer collaboratives and the introduction of hundreds more cancer care consultants into the system. The issue of cancer has been pushed up the agenda by the Government in a way that has never happened before. As many hon. Members have said, cancer in general and breast cancer in particular devastate lives and families. That is why they must be at the top of our agenda, not just this year or next year, but in the years to come.