Cancer missed by two pathologists - report

[Posted: Tue 15/07/2008 by Deborah Condon www.irishhealth.com]

A major report on breast cancer services at University Hospital Galway (UHG) has found that two different pathologists working in the hospital at two different times misdiagnosed a woman’s breast cancer.

Furthermore, in the case of one of these doctors, ‘discrepancies’ were found in a number of patients, which had the potential ‘to affect the clinical management and care for those patients’.

The report by the Health Information and Quality Authority (HIQA) centres on the provision of pathology and symptomatic breast disease services to the patient known as Ms A, by the HSE at UHG.

Ms A was a patient at Barringtons Hospital, a private hospital in Limerick. It was here that she was twice mistakenly given the all-clear from breast cancer, first in 2005 and again in 2007. (A separate investigation into Barringtons by the Department of Health was published earlier this year.)

As was the practice at the time, Ms A’s pathology samples were sent to the pathology department in UHG for analysis. HIQA’s investigation focused on these services provided to Ms A.

The investigation revealed that two different pathologists working in UHG misdiagnosed Ms A’s breast cancer – Dr B in September 2005 and Dr C, a locum pathologist, in March 2007.

As a result of this, Ms A’s treatment for breast cancer was delayed.

In order to ensure that no other patients had been misdiagnosed and to ascertain whether there was a need for ‘wider concern’ about the work of Dr B and Dr C, both doctors’ caseloads were reviewed by HIQA.

This entailed reviewing 200 breast histology patient cases reported on by Dr B and 747 breast and non-breast cytology patient cases and 123 gynaecological cytology cases reported on by Dr C.

The review found that in the case of Dr B, a single interpretive error – the misdiagnosis of Ms A – had occurred and there was no cause for wider concern about their work.

However the review of Dr C’s work identified 49 patients ‘where the reviewers differed from Dr C in their findings’.

“The discrepancies found in these 49 patients had the potential to affect the clinical management and care for those patients and therefore all patients were followed up by UHG and where necessary, were recalled for consultation, further investigation or treatment,” HIQA said.

Of the 123 gynaecological cytology cases reviewed, 35 women whose specimens were reported on by Dr C, were contacted for ‘precautionary follow-up’.

The report noted that some aspects of Dr C’s appointment raised questions for UHG and the HSE, although it acknowledged that the appointment was carried out according to guidance in place at the time.

“As in many countries, the current recruitment process for permanent, temporary or locum consultants does not include objective assessment of technical ability, but relies on the subjective opinion of referees. Clear procedures for the recruitment of temporary or locum staff, including comprehensive guidance on the use of recruitment agencies and guidance on references, should be developed,” HIQA recommended.

It added that such guidance should be applied ‘across the broader HSE’, given the reliance on locum staff within the health service.

The report also noted that there was no arrangement in place for pathologists from UHG to participate in multidisciplinary reviews of cases at Barringtons. As a result, an important opportunity to pick up on the misdiagnoses was lost.

“The fact that Ms A experienced two interpretive errors, separated by 18 months, by two different pathologists serves to emphasise the importance of having fully functioning triple assessment and multidisciplinary team meetings in place, irrespective of where the patient is cared for.

“Failure by the clinicians and institutions concerned to have such arrangements in place was a significant factor in her delayed diagnosis,” commented HIQA director of healthcare quality, Jon Billings.

Overall, the HIQA team found that the symptomatic breast disease services at UHG were well run, however it did make recommendations for improvements in the pathology department’s quality assurance systems.

“The hospital was responsive once the interpretive errors came to light. Lessons learned by UHG in responding to this incident should be examined by corporate HSE to inform the approach adopted nationally,” Mr Billings said.

He added that Ms A had shown ‘great courage at a time of personal difficulty’, in sharing her experiences with the HIQA investigation team.

Responding to the publication of the report, Health Minister, Mary Harney, reiterated her apology to Ms A for what had happened. She said that Dr C is no longer working in Ireland and he has been referred to the Medical Council.

"The system's over-reliance on locums, and the procedures used in recruiting them, is now being addressed by the HSE. The HSE is implementing a series of measures to strengthen its procedures for recruitment in this regard," she said.

Minister Harney added that the report 'reinforces the importance of providing symptomatic breast cancer services in eight designated centres', a policy which the Government is pressing ahead with under the National Cancer Control Programme.

Meanwhile the HSE has said that a review of the work of a third pathologist at UHG is now being carried out. It is undersood this doctor worked at the hospital in early 2004. The decision to review his work was made after the HSE learned that he had been suspended from the medical register in the UK for 18 months due to concerns over errors he had made there.

The hospital has established a helpline for anyone who may have concerns or questions. The phone number is 1800 252 016 and lines are open from 9.30am to 5pm, Monday to Friday.

anonymous  Posted: 15/07/2008 17:12

Minister, what is the connection that reinforces the eight centres? I do not see how this follows. More spin from a spun-out Minister?

JamesH  Posted: 17/07/2008 08:34

Anon, The connection is clear. There was not a triple assessment is this case. There was not a multidisciplanry team reviewing all the cases at Barringtons. All the indications are that these would minimise (not eliminate) the risk of these missed cancers. This is what the eight centres of excellence will provide. The relevant quote is as follows. “The fact that Ms A experienced two interpretive errors, separated by 18 months, by two different pathologists serves to emphasise the importance of having fully functioning triple assessment and multidisciplinary team meetings in place, irrespective of where the patient is cared for." “Failure by the clinicians and institutions concerned to have such arrangements in place was a significant factor in her delayed diagnosis,” commented HIQA director of healthcare quality, Jon Billings.

anonymous  Posted: 17/07/2008 16:13

Bunkum, James.

CATHY  Posted: 17/07/2008 22:36

Bunkum all over again is the right word for Mr/Ms J, the overprotector of the govt and HSE. Where in Ireland is there a triple assessment? none of the hospitals with breast services appear to have triple assessment, not even in the University Hospitals!!The service is being provided there for years. There is no Guarantee that there will be place on the 8 COE's or if they do have , will it work smoothly or will it really minimise errors. We all are human, small or big hospitals, mistakes will happen if there are inadequate resources, staff etc. We have also to accept the fact we have severe shortages of specialist staff, with the current economic gloom, it will prove to be even more difficult to employ frontline staff{oh yes there will always be money to employ more HSE honchos and admin staff!!}Take a look at small hospitals--each of them have a hospital manager, deputy manager, asst manager, business manager and a finance manager, but lack nurses and doctors!! Logic?? Same will apply to these so called COE's mark my words. In meantime, delays and errors will occur and patients will learn to "settle" in corridors

JamesH  Posted: 17/07/2008 23:04

Hi Anon, Don't shoot the messenger. You couldn't see the connection, I'm just pointing out the quote from HIQA that makes the connection. Do you want to elaborate what exactly you think is bunkum. I assume that you don't think the current situation of cancer diagnosis is all that it should be.

CATHY  Posted: 18/07/2008 11:13

We do not need to spend millions on HIQA and other such non-clinical personnel to tell us that Triple assessment is not is place, we know that. HIQA has go in to prevent incidents, not after. As they say, prevention is the best medicine. We do not practice enough preventive medicine in this country. Blame culture will only lead to job vacancies. HSE and Health Ministry should stop blaming one particular speciality. Clinicians are responsible for their patients, so they should take the majority of the blame. All those docs involved in the recent reviews are aware that they themselves have MISSED LESIONS. No one is perfect. The so called experts haven't done anything to improve services over the years.Even the "best" breast centres across Ireland fail to provide basic needs, lack state of art equipment. Local Risk management staff ignore calls for staffing/equipment.

anonymous  Posted: 18/07/2008 13:06

The so-called Centres of Excellence will not deliver what you are hoping for and what we are being promised. There are too many other variables - no money for resources, poor facilities, outdated equipment, outdated drug use, no screening to catch cancers early, poor management, too many vested interests, etc etc etc. and this Government is to blame as they did not use the money properly when it was in the kitty and the main finger of blame must point at Mary Harney.

JamesH  Posted: 19/07/2008 16:19

Cathy, You say that there is no triple assesment in Ireland. 100% incorrect. BreastCheck has implemented triple assessment with all cases reviewed by multidisciplinary teams, since its start in 2000. That is just for starters.

CATHY  Posted: 21/07/2008 10:42

Triple assessments are for "starters" in place ? They are just in place and not used effectively. If they did we won't have problems.The so called experts in Breast services and the experts doing reviews have made no effort to oversee the breast services around the country for donkeys years. It is primarly their fault , as I said prevention is not a byword for these experts.Each review should be conducted by different experts not the same group all over the country..So many things are supposedly "in place" For "starters" please read the sentence again-- "Where in Ireland is there a triple assessment? none of the hospitals with breast services appear to have triple assessment, not even in the University Hospitals!!". For starters{ oh yeah rings like a hotel menu!!} pointing fingers befor the reviews and then denying the whole saga and issuing statements like " triple assessment not in place" is not helping anyone, certainly not the patients.

JamesH  Posted: 21/07/2008 14:22

Cathy, I really don't know what your problem is. You claimed incorrectly that there was no triple assessment in Ireland. I pointed out that BreastCheck has had triple assessment since it started in 2000. You then incorrectly claim that it is not used effectively. BreastCheck has been praised from all quarters for its good work. Do you have a problem with BreastCheck? What is your basis? BreastCheck is linked with 4 of the major hospitals in Ireland, namely the Mater, Vincents, South Infirmary in Cork and Galway UH. That is for starters. St James, Beaumont and Sligo also have effective triple assessment, independently of BreastCheck. These are just the ones that I am aware of from following the stories of the last year.

CATHY  Posted: 21/07/2008 17:46

The problem is not with me or you. It is the fact that Triple assessment is not functioning properly in Breast Check or anywhere. Galway UH has failed {as reported by the HIQA}, the main centre/HUB has failed so many times. PLEASE READ CORRECTLY-- There is triple assessment, BUT IS IT USED EFFECTIVELY??{as stated previously. If Sligo is good, why are they losing the Breast services? I hope have read enough over the years, every place has problem{human?} Breastcheck has failed in its very essence providing to service to every female in the country by not monitoring the service. I don't have to provide facts, they are blatantly in open, for people to choice between accepting or ignoring. What you read in the papers is only the sensational bit, the truth is worse. Triples assessment is a cover up/mocking the very seriousness of cancers.The whole saga is a nasty way to proving that only COE'S work. In ideal world yes, but inreality patients are suffering. COEs or none COEs, cases have be dealt with by Multidisp. not one team.

JamesH  Posted: 22/07/2008 09:21

Cathy, I like you believe that there are many faults with the health system. However we do need to deal with facts and also accept that some parts of the system are working well. BreastCheck has been praised from all quarters as a world-class example of how things can be done. It is 100% incorrect for to say that they are not using triple assessment effectively. I repeat my question; on what basis do you make this untrue accusation? You say the facts are “blatantly in open”. Could you tell me what facts are in the open about BreastCheck. It is also factually incorrect to say that UHG was found wanting in the area of triple assessment. It was in fact Barringtons that handled the MsA case and it was Barringtons that HIQA found did not have triple assessment with all cases reviewed by a multidisciplinary team. Your ascertion that Triples assessment is a cover up/mocking the very seriousness of cancers” just shows how little you actually know about the current thinking in the world of cancer care. Triple assessment is reviewed by the multidisciplinary team. Could you tell me which cancer expert group supports your lubricous view? You started out your arguement saying there was no triple assessment in Ireland. When this was shown to be untrue you then lashed out that it was not being done right in Ireland. And you then go on to make unfounded allegations that BreastCheck was not doing its job well. For some reason you do not want change in the cancer care in this country, despite the many examples over the last year showing that the current system is not up to scratch.

CATHY  Posted: 22/07/2008 13:28

I have worked in so many hospitals around the country, and I know the REAL truth, which you will never understand JH. As you and everybody knows, there is nothing 100%,you are right we have to deal with facts and you should know that so many facts are covered up!!{ eg. inspite of cutbacks,patient care won't be affected-- big misconception of fact isn't it?} If Triple A is world class, why has it failed on so many occassions and why is it not properly in place inspite of the all the "scandals"?? If Breast check is so gooood, why is taking such a long time to roll out all over the country? Cancer care should be for all people all over the country not just COE's, rural cancer is higher than urban. Small hospitals having been doing well for all these years why not support them, fund them and they will be as good or better than most COE's . Waiting lists in smaller hospitals is shorter than those BIG HOSPITALS. Patient will be assessed quicker. Check HSE website for facts. As I said before, earlier the cancer is detected, better the chances, in small or big hospitals, we don't COEs. Every county needs a excellent hospital, no discrimination of where you live. Small country like us should done better during the Tiger years!!

JamesH  Posted: 22/07/2008 15:43

Cathy, Can you highlight which controversies hospitals with proper triple assessment and multidisciplinary teams have been involved in? Neither Portlaoise nor Barringtons had them and this was highlighted as contributing to their problems. No-one has ever said triple assessment will eliminate all errors. That would be ridiculous. In medicine you can only minimise the risk; never eliminate it; I am sure after all the hospitals that you worked in you would realise that by now. You are of course correct in highlighting that BreastCheck has been much slower at expanding than it should have been. Of course that is beside the point. The point of debate was whether triple assessment and multidisciplinary teams were working effectively or not. You said it was happening nowhere in Ireland. I said it was happening in BreastCheck, plus a number of other hospitals. “Small hospitals have been doing well”. Refer to Portlaoise & Barrington’s. “Waiting lists in smaller hospitals is shorter than those BIG HOSPITALS.” Women from Portlaoise pro-actively moved to St Vincents before Portlaoise breast service was closed. “Patient will be assessed quicker”. They were assessed quicker in Portlaoise. You have not grasped what the cancer experts as saying. You cannot have a cancer centre in every county. It is not viable. You will not have sufficient cases to sustain a team of experts. A breast surgeon needs 150 new cases a year to maintain the expertise. This can never happen in small hospitals. The analogy has been used, of being on a transatlanic crossing with a pilot who does it ten times a year, versus a pilot who does it a 100 times a year; which would you feel more comfortable with in a storm mid-atlantic. If you cannot understand the concept, can you at least accept that experts such as Prof Niall O’Higgins and Prof Tom Keane who have worked all their life’s in cancer care may actually know more than you about the best approach to cancer care. There is nothing wrong with centres of excellence. If I had a major head injury, I would want to be treated in Beaumont hospital, because I know that it is the head trauma centre for Ireland and I have the best chance of surviving. I am willing to travel for that care and cases are shipped in every week from all over the country. Likewise if I get cancer, I want to be at the best possible place and am willing to travel for that rather than settle for a smaller hospital with less expertise.

CATHY  Posted: 22/07/2008 18:20

Why do you assume that smaller hospitals have less expertise? Remember all them docs/nurses have undergone same training, if not better.They just choose to work. in "small" hospitals. No one is big or small. I know some consultants who have done better in smaller hospitals compared to the ones in bigger hospitals. Like to like with equipment and staffing, small is BIG. How many times have you crossed the altantic wondering just how many times this pilot has flown, you never go and ask the pilot will you? Likewise low budget airlines have proved to be better than the BIG HIGHFLYERS!!. God forbid you had an accident near Portlaoise or Barringtons/Tullamore/ or even Naas, the COE' Beaumont will never take you directly, you HAVE to have a scan in the nearest "small" hospital and the images reviewed in both places, before Beaumont come to a decision. That is waste of several hours of your precious time.Time is ticking.....Ask the ambulance crew, one cannot choose the hospital you are brought. You are send to the nearest hospital, most likely small hospital!!That is the REAL TRUTH. SO, IN REALITY THE SMALL IS HELPING THE BIG. Similarly, why cannot patients be diagnosed in and near their county before heading for the glorious COEs. By bypassing local docs you are creating a rift and drift phenomenon. Patients are still happy to go to local hospitals, not forced by the Higgins or Keanes. What works in Canada does not fit with Ireland.

last legs  Posted: 22/07/2008 19:25

Good for you Cathy. I agree with you all the way.

JamesH  Posted: 22/07/2008 22:18

Cathy, I never said that small hospitals do not have a function. The point that you either do not get or refuse to accept is that for cancer all the experts say that volume is the way to go. There are a number of reasons. Firstly multidisciplinary teams minimise the risk. As these teams are made up of surgeons, radiologists, pathologiss, oncologists, radiographers, nurses etc, it must be clear even to you that such teams are not viable units for a small number of cancers. As already said 150 new cases per year is recommended for a breast surgeon by the experts (Do you claim to know more than the experts in this area?). Secondly, sufficient volume of cases exposes the team to more situations and therefore builds their experience, and therefore increase the likelihood that they will know how to deal with different scenarios. Thirdly, the best experts in cancer have a keen interest in research.. Such research requires volumes of cases to work on. Therefore without the volumes you will not attract the cutting-edge experts. I have never crossed the Atlantic wondering how many times the pilot has done it. It was an analogy. However, if I was crossing the Atlantic and we hit a storm I would be hoping that the pilot was experienced and had done it more than ten times; wouldn’t you? Are you saying that you are satisfied with the breast cancer treatment in Portlaoise and Barringtons? If so you truly are unique and really do not have a clue. My point about Beaumont seems lost on you like most logic. If you had a major head injury would you not want to be transferred to Beaumont, or would you rather be treated in your small hospital, just because it is so handy!!! I know that I would hope that my family would be shouting to have me sent to Beaumont. I don’t know what you have against Prof Higgins and Keane, but again logic eludes you seeing as they have a life-time building up expertise but you just want your handy small hospital and to hell with what the experts say. I am glad to see that you have dropped your unfounded allegations of ineffectiveness against BreastCheck.

last legs  Posted: 23/07/2008 18:25

How disgusting to read your answer JamesH and write so arrogantly of Cathy. You owe her an apology and really need to tone up your debating skills. Who are you to speak down to her like that?

JamesH  Posted: 24/07/2008 10:00

Dear Last Legs, My post was purely based on debating facts and was in no way personal. Can you debate which of my facts you believe to be incorrect and why.

last legs  Posted: 24/07/2008 17:47

Its not what you said but how you said it. I have no intention of debating anything with someone like that.

JamesH  Posted: 24/07/2008 20:11

Dear Last Legs, The future of cancer care in this country is a very serious matter worthy of serious debate. The country has two choices, to remain with the current system, which delivered the Portlaoise & Barringtons controversies, or alternatively take action based on the recommendations of a team of cancer experts who have studied the international research in the area. I am 100% behind the concept of the centres of excellence on this basis and in my post of 22/7 tried to highlight three sound reasons for this. If there is anything wrong with my three reasons, by all means point them out. I am merely debating the issue with Cathy, and to be fair to her, while she vehemently disagrees with me, and I believe she does not fully understand the logic of the concept of the centres of excellence, she has never shied away from debate and has always stood by her beliefs and has stood up for them as best she can. This is a welcome alternative to your childish “oh I didn’t like the tone that you spoke to me in, so I'm not going to speak to you”. Grow up and stand up like an adult. If you believe in something you should be willing to defend it; anything less is contributing zero to the debate.

CATHY  Posted: 25/07/2008 09:39

Thank you last legs for you support. At least some one agrees with me. One support at a time adds up. JH, the truth is best known when you work in the real life.The real experts are those who go the root of the problem and try to learn from them. Prof H and K have never visited the smaller hospitals eg Portlaoise and come with high flung ideas. Flights of fantasy don't work, There is lot more than meets the eyes. There are thousands of patients shouting to be sent to COEs but COE have no beds to accommodate these patients. The are more than thousands who would like to stay local. Just seeing numbers don't make one a super doc. I know cases where the experts have missed simple diagnosis which our docs picked up in one go!! The big experts rarely talk to "small" experts.

anonymous  Posted: 25/07/2008 09:57

Once again you have not read my post - I did not take issue with what you said, though in normal circumstances I would, but I rejected the manner in which you expressed it - e.g. 'My point about Beaumont seems lost on you like most logic'. That is a cheap below the belt remark. Argumentum ad hominum. From now my contribution to this topic will be zero.

JamesH  Posted: 25/07/2008 13:48

Anon/Last lges, You say "From now my contribution to this topic will be zero." I would say that so far your contribution has been zero, since your only point has been that you didn't like the tone of my voice. You have never dealt with the substance of what I have said.

JamesH  Posted: 25/07/2008 14:05

Cathy, First off I do live in the real world. You are disagreeing with people who have worked all their working life at the pinnacle of the cancer care fraternity. Prof Keane and O'Higgins are well regarded amongst all the cancer world. What makes you say that they are not? You do not have the careers these men have had without being well regarded by your peers. You seem to have forgotten that Prof Keane was instrumental in setting up the BC Canada system, which as you know has 4 centres serving a population similar to Ireland but the size of France and Germany. So it is far from the world of fantasy he works; it is in the real world of action and results. To get away from your unwarranted personal attacks on Prof Keane & Higgins, could you address my three points on 22/7 explaining why Centres of excellence are the way to go. Can you explain the logic of rejecting these three points in favour of a system that gave us Portaoise.

JamesH  Posted: 25/07/2008 15:16

Hi Anon/Last legs. I had to google your latin phrase. "argumentum ad hominem" (Latin: "argument to the man", "argument against the man") consists of replying to an argument or factual claim by attacking a characteristics of the person making the argument or claim, rather than by addressing the substance of the argument or producing evidence against the claim. I think the phrase sums up your contribution pretty well, seeing as you have been unwilling to debate the substance of my argument. Instead you prefer to prance off in a childish huff taking offence on behalf of Cathy. Cathy seems to be a perfectly robust person well capable of standing up for her opinion. As I said before grow up and be prepared to make your case like an adult; otherwise you will continue to add nothing to this debate.

RkHANNA  Posted: 28/07/2008 10:49

We all need to grow up and stop this nonsense. We all know that things are so slow in Ireland, and it will be the same with the roll out of the Centres. I agree with some comments-- what works in other countries does not really work over here, with or without the so called peers. There are enough working in the system for years who can do a better job. Docs who have little idea of the system will cause long term probs. Persons like Doc Crown would have been a better person, but govt don't like his criticism{ like some members in this group}. We all should be ready for critics, we will only learn from them. JameshH, family and friends shouting for transfer to Beaumont does not help, Beaumont will only take cases that they think will benefit, otherwise the hospital will be flooded with "shouters". That is the system, my friend, that is the way it works, Shouting hasn't solved medical probs.I agree with Cathy when she says the only way to prepare for the best is to go to the roots of these alleged problems. I am amazed that the Peers of the cancer cure haven't done the very basic of problem solving.Are they too big to visit small centres?People and patients are same all over the country, they all should be treated the same way. It looks like only some patients get special attention. The so called peers should stand and repeatedly comment-- errors occur, we should stop making a big deal out of it. This does not mean there is room of errors. Each hospital should be financed appropriately. Monies are wasted on reports/reviews/consultantions, rather than on patients. Until then you keep shouting for transfer to centres of E.

JamesH  Posted: 28/07/2008 12:05

RkHANNA, I agree that relatives shouting won’t get me into Beaumont if I have a head injury and that only cases that benefit will be let in. That is only right and correct. My point was that Beaumont is seen as a centre of excellence for major head injury and people are willing and actively seek to travel to Beaumont, because they know that should they be a case that would benefit, they will be operated on by the best in the country with the best equipment in the country. Prof Crowne agrees with the principle of the centres of excellence (as do all cancer experts). He does have some queries on the location of some of the centres in particular the Dublin based ones. However, like all cancers experts he agrees that each centre needs a critical a mass of cases in order to develop and maintain the level of expertise to have the best outcomes. Don’t forget that he himself works in Vincents, one of the biggest centres in the country. He has never advocated delivering primary cancer diagnosis and surgery through an ad hoc, fragmented, unplanned structure such as we have at the moment which delivered the Portlaoise situation. I have listened to Prof Crowne many times and would be admire his passion and commitment and would agree with what he says. He doesn’t agree with everything the Gov is doing, but in the area of cancer care he does agree with the general principle but not some of the detail. When the centres of excellence are up and running, everyone will have equal access to world class cancer care based on international research. Nobody will have to shout for that. If small hospitals are such a good way to go, why wouldn’t Prof Crowne go to a small hospital? Ask yourself that question.

anonymous  Posted: 28/07/2008 20:06

Rubbish. I have a Garden Centre and I advertise it as the biggest with best choice, best advice and best results. Why? because it benefits me that as many people as possible come to me. Consultants, your experts, all benefit from bigger numbers coming to them and there are many perks for them from other sources when they have plenty of patients -ie they have a vested interest to claim as they do. Your claim re. equal access is totally false not that it matters as the COEs will never be up and running properly anyhow because of financial constraints.

JamesH  Posted: 29/07/2008 10:51

Anon, You say "consultants, your experts". I am interested in who you consider experts in the area of cancer care if not consultants. Which would you rather operationg on your in the case of Breast Cancer, a surgeon who deals with 10 new cases a week or a surgeon who deals with 10 new cases a year? This is not gardening we are talking about. It is the life threatening disease called cancer; a much more serious matter.

anonymous  Posted: 29/07/2008 13:09

Can you understand what I said? Who is driving the change and for what reason. Of course cancer is serious and so are many other ailments so we need to look at the wider picture and get it right. We cannot sacrifice some patients for the benefit of others and we are not getting it right at the moment.

JamesH  Posted: 29/07/2008 15:16

No Anon, I actually cannot understand what you are saying. Change is being driven by the dept of health. The reason I would have thought was obvious; the current situation is far from perfect and in need of much improvement. (Refer to Portlaoise and Barringtons as examples). No-one is suggesting sacrificing any patients. A group of cancer experts looked at the international research which showed that the best survival was from specialist centres with a sufficient volume of cases. That is what the cancer strategy is. You can have a strategy for one ailment. We did it in the 1950’s and eradicated TB. We are in agreement on your last sentence; we are not getting it right at the moment.

anonymous  Posted: 29/07/2008 18:22

I do not agree that the Dept is driving the current method of change. Other illnesses are suffering as money is being diverted. Portlaoise and Barrington's happened because the Irish Government lives in a world which is 15 years behind the rest. Hindsight is terrific. Volume is a small part of better outcomes. Early detection, good diagnostic systems, general health and many other things have greater impact. The people of this country are being led up a garden path - raising expectations of the great cure for our ailling system but that is not what we will get from current plans.

JamesH  Posted: 29/07/2008 22:36

Anon, if you do not think the DOH is driving the change who do you think it is? The DOH set up the expert group who drew up the strategy last year, and also appointed Prof Keane to implement it. Looks like they are driving it to my eyes. You are correct that early accurate diagnosis is critical. This was absent in Portlaoise due to a lack of effective triple assessment and multidisciplinary team reviewing all cases. This was because there was not sufficient volume of cases to make such a team viable. In addition volume of cases exposes the team to more scenarios and makes their diagnosis more effective based on experience. So accurate early diagnosis is related to volume. The proposed Centres of excellence will have a primary focus of accurate early diagnosis. For some reason you are opposed to the strategy that has been drawn up by cancer experts based on international research. Yet I assume that you do not support the status quo. So what is your solution and what is your basis and how come it has eluded the cancer experts. I note that you have dropped referring to Prof Crowne now that it has been pointed out to you that he supports the concept of large centres and actively works in one of the largest in the country.

anonymous  Posted: 30/07/2008 11:58

The consultants who will increase their bank balances are driving this type of change. In this day and age of technology there are other ways. By the way - I have never referred to Prof Crowne, but yes, he works in a major centre.

JamesH  Posted: 30/07/2008 19:20

Anon, I think that with the new contract for 240k that the consultants negotiated they have already managed to get their money. Apologies re my ref to Prof Crwone, that was another contributor. My point still stands that if you don't want to follow the advise of cancer experts who have studied the international research, whose advice do you want to follow and on what basis?

CATHY  Posted: 04/08/2008 01:02

NO, we haven't got rid of TB, not here, not in any developed or developing countries, cases are still reported everyday. NO patients cannot make a decision as to where they are sent for treatment, chronic cases may have a choice, but acute cases, God help them. NO, none of the so called experts will want to work in "small hospitals", they know they will be no funding, no state of art equipment, no private monies{!!! sic}, YES, small hospitals are targeted, used as scapegoats, fall guys to justify "big" centres. Volumes, talk about volumes? Check A/E activity in hospitals around the country, some "big " hospitals have considerable less volume than small hospitals. Does that mean , the docs and teams in these hospitals do not have the same experience as the ones in smaller hospitals??Now does the volumes justify the existence of A/Es at these hospitals???? Conduct a review, in each and every hospital in the country, YOU CANNOT HANDLE THE TRUTH, fair audit will show that all hospitals are functioning sub optimally!!

JamesH  Posted: 05/08/2008 11:56

Big urban area a “well-woman” centre. Cathy, you say “Fair audit will show that all hospitals are functioning sub optimally”. You are probably correct. In the case of cancer care specifically (and not any red herring re A/E) volume has been accepted by all the cancer experts as the way to go. If you know more than them and can prove it I am sure they would welcome your views. We have a situation where cancer care was being provided in an adhoc, fragmented, unstructured way in over 30 hospitals. This would explain why they are performing sub-optimally. The cancer strategy will deliver cancer care in a structured basis to a national programme based on the advice of experts who reviewed the international research. You clearly do not like cancer experts and their opinions, but I am sure that were you or I unfortunate enough to get cancer, we would both want the advice of the correct cancer expert.

anonymous  Posted: 05/08/2008 15:19

What is a 'correct expert'? There is no such thing as a cancer expert. Every cancer is different as every patient is different and will react differently to a specific form of treatment. There is no 'fits all' solution here. It is when doctors become convinced that they are 'experts' that the problems surface. It is when 'expert spin doctors' are good that people are convinced of notions that are untrue and raise false expectations. Good doctors are good doctors irrespective of volume but it is not just the doctors that matter - the whole system for care of whatever ailment is responsible for the outcome and this goes right down to the facility in which treatment is received.

JamesH  Posted: 05/08/2008 18:38

You are correct there is no such official title of cancer expert. When I refer to a cancer expert, I have in mind a generic cover-all term referring to a consultant level doctor specialising in cancer-care. Included would be public health specialist or epidemiologist, especially if they have a special interest in cancer. You are correct there is no one-size-fits-all solution. However, in health care research is published in peer-reviewed journals and based on the evidence either becomes accepted or rejected; it has nothing to do with spin. In the world of cancer-care, all the specialists (do you prefer that word) are in agreement that volume works. Examples of such experts would include Prof Keane, Prof O’Higgins, and Prof Crowne. Between them they have probably 120 years experience in cancer-care; that in my books makes them experts. If you have anything close please let us know. There were hospitals where a general surgeon was carrying out 10 breast cancer surgeries a year. There is no way that such a surgeon’s expertise in breast cancer surgery can compare to a specialist surgeon doing 150 new breast cancer cases a year. Volume certainly is critical in this area. It is correct when you say that it is about much more than individual doctors; it is about good systems, equipment, clinical audit, experience of unusual cases. This is all clearly going to be better in a high-volume centre. A low volume hospital simply cannot sustain a multidisciplinary team going.

anonymous  Posted: 06/08/2008 13:51

I'll say again - there are no 'experts' in cancer care and there are no 'specialists'. There are those who are specialising in cancer care but outcomes would be much better if they were expert - as a matter of fact they would have halted the growth of the cancer in the first place. Also the doc is only a cog in the wheel of care. Lets not make Gods out of mere mortals.

CATHY  Posted: 10/08/2008 20:55

I must have written a million times, docs in small hospitals are experts as well. they were employed because of their" age", they also have to undergo the same training, the same appointment process. They are not lacking expertise. All they lack is state of art equipment, not 15 year old machines, inadequate staff. Big hospitals won't take a walk in patient, they have to be diagnosed in their local hospital and all the reports etc sent to the so called experts in big hospitals. So in the process the patient is the loser.

JamesH  Posted: 11/08/2008 10:20

Cathy, just because you say something a million times does not make it true. Do you believe that a general surgeon doing 10 breast cancer operations a year can possibly have the same amount of expertise as a specialist surgeon doing 150 cases a year? Answer that in a straight forward and honest way. The cancer diagnosis will not be happening at your local hospital. This comment of yours clearly illustrates your lack of understanding of the concept of the centres of excellence. The diagnosis will be happening at the centres of excellence, as will surgery and radiotherapy. Follow-up chemotherapy can be delivered at your local hospital

anonymous  Posted: 11/08/2008 11:37

Every patient is different, every body is different, every cancer is different, every hospital is different and so is every consultant. I have a recurring emergency problem which requires surgery every two years or so. I had it done on two occasions by general surgeons in my local hospital and there were no complications either time. The last four times I have had to travel a three hour journey to reach the "Centre of Excellence" where the operation was carried out by a 'specialist' 'expert'. Each time I have had to go back to theatre a second time because of complications, where the 'specialist' did not carry out the procedure properly. Don't tell me about 'experts' and volume.

JamesH  Posted: 11/08/2008 11:56

Anon, You are of course correct when you say that every case is unique. However, the national cancer care programme is being set up on the basis of survival outcomes studied over large numbers of cases and the evidence is undeniable that survival rates are better by-in large high volume hospitals. There may be individual exceptions. Naturally we do not have the details of your case, nor am I asking for them. But on the face of it if you require surgery every two years, it seems likely that your conditions is getting more complicated with time and that this may be contributing to second surgeries. If your local hospital was successful the first two times, why were you sent to the larger hospital the last four times. Seems to me possible that your local hospital decided 8 years ago that your case needed greater expertise than they felt they had.

anonymous  Posted: 11/08/2008 17:45

Re.personal - the last time I had to have second surgery to remove a piece of equipment, which was left behind first time!! The local surgeons felt that perhaps the 'expert specialists' in the COE would be able to do something to prevent the condition recurring but no. Can you please quote me the references for the studies carried out.

JamesH  Posted: 11/08/2008 19:14

Anon, Of course on a personal note I do feel sorry for your situation and a second operation to remove equipment left behind is absolutely terrible and shouldn’t happen. I presume the 4 operations where you needed a second surgery in the bigger hospitals didn’t all involve going back for left-behind equipment. Therefore again I have to assume that a condition that has needed 6 operations over that last twelve years or so, is a fairly complicated one. Obviously if your local surgeon let you go back to the bigger hospital for 4 operations, then your local surgeon had good reason for doing so. Not wanting to dismiss your situation, it isn’t really relevant to the new national cancer care strategy. The concept of a centre of excellence was only introduced last year and none currently exist. Re the studies on cancer survival rates; no I don’t have them and haven’t read them. What I do know is that every cancer expert and every organization involved in cancer care in the country supports the cancer-care strategy and that is good enough for me. If know something that they don’t well bring it on.

anonymous  Posted: 12/08/2008 12:06

I think you should look for the data and the proof, see who carried out the research, what method was used, who paid for it, who and why certain groups are promoting it and how it has been presented to the public.

JamesH  Posted: 12/08/2008 14:04

Anon, I like you am an interested amateur. If you have some sinister allegation to make against the cancer experts and all the cancer organisation in the country, why don’t you go right ahead and make the allegation. If you don’t trust these people to give you the correct advice re cancer-care, who would you suggest to be the best source of advice? Incidentally assuming that you have a better source for advice, what advice are they dispensing and what is their explanation for why it differs from the cancer experts?

anonymous  Posted: 12/08/2008 19:21

You believe what you are told and want to believe. I will continue to believe differently but as the powers that be are prepared, for their own reasons, to go with those whom you believe, I cannot see that I could influence them to look again, but the day will come when they will be shown to be mistaken. By then it will be too late for many.

JamesH  Posted: 13/08/2008 10:21

Anon, I have many times said that I support the cancer-care strategy on the basis of support from all the cancer organisations and cancer experts in the country. You may well have a better way, I don’t know because you haven’t articulated what you would do instead. What I am asking is what is your proposed better way, on whose advice have you decided on this better way if not the cancer experts and finally have you any rationale as to why your better way differs so much from the cancer experts?

anonymous  Posted: 13/08/2008 10:48

You show me the proof of what you believe other than following blindly.

JamesH  Posted: 13/08/2008 11:18

Anon. The proof is the support of all the cancer organisations and cancer experts in the country. That’s good enough for me. Now are you ever going to step up to the plate with your alternative plan, and whose advice you would follow instead of the cancer experts and why their advice is better than the cancer experts. You haven’t provided anything of substance except auld guff about conspiracy theories of the cancer fraternity trying to prevent good cancer-care “for their own reasons”, without ever enlightening us as to what your great idea is instead. So either cough up or get off the fence.

Cally  Posted: 14/08/2008 16:39

While I can see the point in having COEs, but I still feel that life will be harder for those in places like the North west. What is going to happen in between the time they close / down grade smaller facilities and set up the COEs? People needing treatment will be left to wait and suffer.

the yikes  Posted: 18/11/2008 22:32

Hi, okay to most who read this it may seem silly and laughable but from where I'm sitting it is a terrifying place to be. For a few months now I've been suffering from a cough and over the last 2 months it's gotten worse. It's at the point now where once i start coughing it only eases after i have vomited or collapsed in a heap in the bathroom. I visited my GP today and he examined me. As he put the stethoscope to my chest he simply said and I quote, "Oh my lord" at which point he said he would like me to go for an X ray right away. Now I'm not the most medically clued in person ever to walk the earth but hearing my Doctor say that and seeing the look in his eyes i have to say that I am 100% scared. If anyone has had a similar experience to this can they please PLEASE tell me the outcome? I should mention I do smoke 25 a day. Please can someone give me a clue as to what i MIGHT be facing because i am scared witless. Thank you.

brandy  Posted: 24/11/2008 20:29

the yikes, Seems it might be impossible....but you have to try and not think the worst....wait 'till you get results of test....you may just have a bad chest infection. GIVE UP THE SMOKES IN THE MEANTIME....hard as it is....you're not helping yourself if you don't. Good luck and think positive.

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