With the current national cancer strategy due to end in two years, David Lynch reports on some pressing issues that need to be addressed
Between 2013 and 2022, the mortality rate from cancer in Ireland fell by 11.4 per cent, according to the Department of Health’s Health in Ireland Key Trends 2023.
The Irish Cancer Society (ICS) notes that more people in Ireland are surviving cancer than ever before.
So while progress has been made in cancer care over the past decade, as we enter the final years of the National Cancer Strategy 2017-2026, doctors have also raised concerns over continuing challenges.
A European Commission report last year found that Ireland had the second highest incidence rate of cancer among the 27 EU member states. The ICS states that an estimated 42,000 people in Ireland get cancer each year. The demand for care remains high, especially with the delayed diagnoses and lengthening waiting lists that occurred during the Covid-19 pandemic.
Strategy
Speaking at last month’s National Health Summit in Croke Park, Dublin, ICS CEO Ms Averil Power agreed the centralisation of cancer surgeries “has made a massive difference” for patients. She also said that investment under the first two national cancer strategies “did improve outcomes in Ireland quite significantly”.
However, she admitted the Society had concerns. “Things have stagnated in recent years and that is because we haven’t seen the same level of investment or political priority to the third national cancer strategy.”
Ms Power told Summit attendees the current strategy only received dedicated funding in two of the Budgets since it was published.
She said there was major concern within the “cancer community… that we are not only stagnating, but that we are at risk of going backwards”.
Asked by the Medical Independent (MI) about these concerns, the Department of Health pointed to a 25 per cent improvement in five-year survival rates for cancer (excluding non-melanoma skin cancer, which is close to 100 per cent) in the period 2014-2018 compared to 1994-1998.
“There are now over 215,000 people in Ireland living after a cancer diagnosis,” the spokesperson told MI. The spokesperson also referred to developments within the oncology field in Ireland. These include new models of care for medical oncology and psycho-oncology; the delivery of new treatments including CAR T-cell therapy for adult patients in 2021 and children in 2022; and peptide receptor radionuclide therapy for neuroendocrine tumour patients in 2024.
Regarding the organisation of services, the spokesperson pointed to the “continued centralisation” of cancer surgeries to designated centres. They also noted the new radiation oncology facilities in Cork and Galway “which can treat more patients and deliver new treatment types, such as stereotactic ablative radiotherapy, benefitting patients with more targeted treatment in fewer doses”.
Asked when work on the next national strategy will begin, the spokesperson replied that there are still two years remaining for the current plan.
The focus in the next strategy will be on “improved outcomes for cancer patients through the delivery of multidisciplinary care for cancer patients, with clinical cancer research as an integral component”.
Digital
Those working in cancer services stress there are a number of issues that need to be addressed as a priority.
“Physical and digital infrastructure is the biggest issue, I feel,” according to Prof Seamus O’Reilly, Consultant Medical Oncologist, Cork University Hospital.
“We lack clinic space to see patients and existing inpatient accommodation is neither infection control nor dignity-appropriate.”
Prof O’Reilly said he believed the establishment of a taskforce to focus on both physical and digital infrastructure “would be helpful”.
“In 2030 we will, by EU law, need electronic records for all patients,” he told MI.
“Now is the time to start that and to harmonise it so that your GP and your liaison nurse have access to the same information – the EU law could be the catalyst we need for this.”
The importance of digital advancement across the health service features prominently in the new National Cancer Registry Strategic Plan 2024-2026. The plan was launched by the Minister for Health Stephen Donnelly earlier this month.
Physical and digital infrastructure is the biggest issue
According to the Registry, the “anticipated advances” in digital health systems are “pivotal”.
“The implementation and integration of these digital systems are essential, with many of our objectives contingent on this,” the plan states.
Transformation
Recent years have seen advances in robotics and artificial intelligence (AI) use in cancer care in Irish hospitals. Experts believe that improvements in wider digital infrastructure are important to underpin this technological change.
AI deployment in cancer surgery was discussed at the Policy Forum for Ireland seminar, entitled the ‘Next steps for cancer services in Ireland’, which was held online on 7 March.
Prof Ronan Cahill, Professor of Surgery, Mater Misericordiae University Hospital, Dublin, spoke on the developing role of AI in improving cancer patient outcomes.
“AI is increasingly common in healthcare,” Prof Cahill told attendees.
“It is often seen as a way of optimising efficiencies around operations, but really where we need it is in operations, to shift our outcomes and improve safety.”
Asked by MI how important digital transformation was for AI use in cancer care, Prof Cahill responded: “Enormously.”
“It does require the Irish health service to be a leader,” he said.
“So, of course, patient identifier numbers linked up with digital infrastructure [is] absolutely essential.”
Dr Grainne O’Kane, Director of the Cancer Clinical Trials Unit at Trinity St James’s Cancer Institute, Dublin, previously told MI that the slow pace of digitalisation within the health service is a “huge frustration”. Speaking to this newspaper at last month’s Health Summit, Dr O’Kane said improved digital infrastructure was vital to patient care.
“I think the use of a unique [patient] identifier and an electronic medical record in this country would transform care and improve efficiencies,” she said. Dr O’Kane added clinicians in oncology and other specialties shared her “frustration” at the lack of a national integrated digital infrastructure.
Inequality
On the specific challenges directly facing consultant oncologists working in the health system, Prof O’Reilly highlighted that access to new therapies is a “major issue”. For example, he said the new agent trastuzumab deruxtecan (Enhertu), which can treat adult patients with breast cancer, stomach cancer, and non-small cell lung cancer who fit the specific criteria, can only be accessed by patients, who have health insurance, within the private sector.
He predicted that this situation will worsen “as more and more agents are approved at European level, but are too expensive for the State to pay for”.
In recent months, a number of oncologists publicly raised concerns regarding certain cancer drugs and therapies being available to some private patients, but not available through the public system. This situation has also been noted in primary care.
“GPs are aware of this issue and were surprised at the focus on the availability of these drugs under different private schemes with so little emphasis placed on their lack of availability for public patients,” Prof Susan Smith, GP and Professor of General Practice at Trinity College Dublin, and member of Deep End Ireland, told MI.
“Though we also accept the need for independent evaluation of the cost-effectiveness and budget impact analysis of new treatments.”
GPs have also raised a number of other examples of inequality faced by cancer patients (see panel).
Reimbursement
Early last year, Minister Donnelly published a report prepared by Mazars that examined the governance arrangements around the HSE’s drug reimbursement process.
A Department spokesperson told MI that the implementation working group held regular meetings in 2023 and two rounds of targeted stakeholder engagement.
The spokesperson added the implementation group’s report has been drafted and will “soon be finalised” and submitted to the Minister.
“The Minister for Health and the Government are committed to providing timely access to new and innovative medicines to all patients. Budgets 2021 to 2023 provided almost €100 million of dedicated funding for new drugs. This enabled the HSE to approve 148 new drugs, 61 of which are for cancer,” said the spokesperson.
There will be “significant investment” in additional staff resources this year to enhance the HSE’s medicines pricing and reimbursement process, they added.
Rehabilitation
The importance of rehabilitation services for cancer survivors has gained prominence in recent years.
Prof Juliette Hussey (PhD), Professor in Physiotherapy, Trinity College Dublin, told the Policy Forum for Ireland seminar that the need for “rehabilitation as part of [cancer] survivorship” will increase as the numbers of people who survive cancer increases over the coming decades. She added that psycho-oncology care provision is recognised in the current cancer strategy.
Prof Hussey highlighted the appointment of additional nursing, psychology and psychiatry staff working in the area, as well as social workers.
“That has really complemented existing services and has grown them quite significantly.”
Asked by this newspaper how she would rate the implementation of the cancer strategy in terms of rehabilitation services, Prof Hussey said there was “a considerable increase in services”.
“You can see that with the number of locations and hospitals that are developing oncology-physiotherapy [services],” she told MI.
“It needs to be higher. There is a problem with the shortage of healthcare professionals, so it is not always easy to fill these positions. I think we are running to catch up.”
Regions
At the same online seminar, Prof Michael Kerin, Chair of Surgery, University of Galway and Director, Saolta University Cancer Network, outlined the regional imbalances in access to cancer care in Ireland, particularly in the northern and western regions. He said the lack of capital health infrastructure, particularly in the regions, was a problem.
“Our problem in delivering appropriate care is, apart from the regional imbalance, the lack of capital investment,” Prof Kerin told the conference.
However, he added that the inclusion of a cancer centre for the west of Ireland in the National Development Plan was a positive development.
Asked by MI whether the six regional health areas may improve provision in the regions such as the west, Prof Kerin said: “I think so – yes.”
In February, this newspaper reported that the Director of the National Cancer Control Programme had written in October to the HSE Chief Clinical Officer to request that a cancer clinical director be appointed to the senior management team in each of the health regions.
A HSE spokesperson told MI that “work to operationalise the health regions is ongoing and further details will be available in due course”.
The view from general practice – inequality in cancer provision
Deep End Ireland is an organisation of GPs working in socio-economically deprived communities.
Following a request from the Medical Independent, Deep End Ireland members reflected on the continuing impact of disadvantage and inequality on their patients’ care in relation to cancer services, as well as some positive developments.
Dr Sarah Fitzgibbon highlighted the significant association between deprivation and cervical cancer, with a difference in relative risk between the areas with the lowest and highest quintiles for levels of employment.
Dr Cliodhna O’Callaghan from Limerick also pointed to the lower uptake of some cancer screening programmes in disadvantaged areas and said that this information can be used to inform research aimed at reducing these inequalities.
Dr Edel McGinnity, Mulhuddart, Dublin, referred to the higher death rates from cancer in disadvantaged areas. This is due to societal inequality, but also because patients present at later stages of disease. She also noted challenges created by patient volume, acute health, and social problems. Also there is often a lack of time for consultations so the GP is less able to engage in screening and early detection.
Also in Dublin, Dr Brid Shanahan, Summerhill, noted that the National Cancer Control Programme referral pathways have been “great at levelling the playing field” in terms of diagnosis of cancers. However, she said there is still a “huge disparity” in speed of diagnosis of the cancers not under those pathways. Dr Shanahan gave the example of head and neck cancers and the long waiting times for urgent cystoscopy. She noted that patients with insurance, or the ability to pay, get treatment sooner by accessing the private sector.
Dr Tadhg Lehane, Dublin 8, said there have been a number of young patients diagnosed with cancer in his practice area. This has been partly due to advances in access that has come through HSE Social Inclusion, according to Dr Lehane. It is also due to a better understanding and acceptance of the complexities of addiction and how they interplay with treatment plans and services, particularly palliative care once diagnosed. He said that initiatives such as peer advocates “have improved attendance and have also helped with access”.
Dr Anna Beug, who is based in the Coombe Family Practice, Dublin, highlighted the long-term impact on physical and mental health for people who have experienced trauma in childhood. She said there were well-established connections between poverty, attachment trauma, lack of early intervention services, substance misuse, and later development of cancer.
Dr Vivenne Wallace in Dublin said obesity is a significant risk factor for cancer and is much more prevalent among poorer people who are much less able to pay for bariatric surgery or diabetes medicine such as Ozempic.
Dr Eoin Monahan, Cork, reflected on his experience working in a disadvantaged community with cancer patients who frequently have to be referred for emergency department assessments and admissions.
Dr Monahan said these patients often have challenges coping with the hugely significant stress that cancer has on their lives, in addition to other significant physical, psychological, and social issues.
He added that such patients “also struggle with the financial impact”, for example, the petrol and car parking costs incurred from multiple attendances at hospital.
For more info on Deep End Ireland see http://deepend.ie/
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