We're close to world-class service - cancer chief

[ by Niall Hunter, Editor www.irishhealth.com]

National Cancer Control Programme Director Prof Tom Keane says he believes Ireland is now very close to having a world-class cancer service thanks to recent reforms.

Prof Keane, who, has been implementing a controversial cancer services reorganisation since his appointment in late 2007, said it is impressive that Ireland has now achieved for breast cancer what many other countries are nowhere close to achieving.

In an extensive interview with irishhealth.com, the cancer services chief said breast cancer services will have moved out of Tallaght Hospital in Dublin and the South Infirmary in Cork to designated centres by the end of the year, and the plan to transfer and reorganise other cancer services is on target.

On the recent controversy over the transfer of breast cancer services from Sligo to Galway, Prof Keane said there were issues in play in Sligo around concerns over the hospital's future that had nothing to do with cancer.

He said: "The Sligo people will hopefully in time begin to understand that it was the right decision."

He dismissed concerns about the funding and resourcing of the eight designated centres, stating that funds will continue to be ring-fenced for the cancer service, and said tremendous progress had been made in meeting HIQA's quality standards in the eight breast cancer centres.

Prof Keane said previous cancer misdiagnosis controversies occurred because the correct processes were not in place at the time. He said it was not feasible to provide optimal cancer care in 35 hospitals in a country the size of Ireland.

Currently on secondment from the British Columbia Cancer Agency in Canada, Dublin-born Prof Keane's term as interim director ends in November.

He said there were no plans for him to continue in Ireland after his two-year interim directorship ends in late November and he intends to return to work in Canada. "The plan was that I would get it up and running and the HSE would then recruit a permanent director."

Prof Keane,who is a consultant radiation oncologist, says he believes the Irish health system is fragmented, but a lot has been done to bring it together. While Canada has a totally public system, he does not believe there is evidence that the proliferation of private medicine in Ireland inhibits access to care.

Read the full interview below:

Are you happy with the progress that has been made on reorganising cancer services?

Yes, I think despite the occasional bouts of turbulence things are pretty well moving the way we want. Obviously there is a lot more to the programme than just the breast cancer service which gets probably an undue amount of attention because of the political nature of that but there are many other aspects to the programme that are moving along. It’s on target. Generally speaking, at the rate that things tend to get done here I am happy we are moving ahead.

When will the remaining breast cancer units transfer to the major centres?

The last date for new referrals to Tallaght is the end of the month. Then there will be a period to wind down regarding patients already in the service. That will take another possibly two months with a timeline of around the end of October to phase out the existing service. So patients are already being referred on the expectation of services moving. There have been no issues with the GPs. We anticipate that about 40% of the Tallaght breast referrals will go to St Vincent’s and 60% will go to St James’s.There were some initial concerns expressed but the board of the hospital has bought into the process.
The move of the South Infirmary service to Cork University Hospital is awaiting the completion of the development at CUH, which will be finished at the end of November. This is a major new ambulatory care cancer centre. The transfer will take place some time around mid-December. Regarding the argument against moving the breast service from the South Infirmary to CUH, I have a letter from the Chairman of the Board of the South Infirmary who acknowledges that the new cancer centre will be better than either what the South Infirmary or the old CUH had individually. The capital development at CUH is also providing space for other cancer investigations and treatments as well as breast.

Was there a case, even a marginal case, for a unit or even a satellite unit at Sligo?

Well, I’ve made my position clear on that. One has to understand that in 2007 there were only about 400 patients who had surgery for cancer in Sligo and of that 400 some 260 were skin cancers. So other than breast and a modest volume of colo-rectal cancer, nearly all other cancer surgery that is not done in Sligo is sent to Galway or Dublin.
So lung, brain, prostate, all those things don’t stay in Sligo right now. They had a breast service but it never had the critical mass to be a cancer centre. They did not meet the criteria, and the decision has been made.
If you were to make an exception for Sligo you would have to make an exception for virtually every other centre of similar size in the country.

In general, were you surprised at the level of local protest in some areas?

There were a lot of strong feelings in Sligo from the very beginning. We waited for a long period in order to demonstrate to Sligo that we could successfully transfer services to the satisfaction of local patients and communities everywhere else in the country. The transfers now have happened right across the country and have been done extremely well. We have only moved services when we were ready and if you were to go to Castlebar now you would find that people are very happy with the service following the transfer to Galway. Similarly in many of the other places. But there are other issues up in Sligo around concerns over the future of the hospital that have nothing to do with cancer. Cancer surgery represents a tiny tiny fraction of the workload - the biggest single workload in Sligo hospital is chemotherapy and that is not moving.

Was there similar local opposition to centralising services in Canada?

There is a much greater acceptance of this in Canada because of the distances that patients travel for unique services, particularly surgical. There was an acceptance that cancer control required centralisation.

But do they not have plans to build an additional regional cancer unit in British Columbia?

You’ve been reading the wrong stuff. The unit in the city concerned, Prince George, is a radiotherapy facility for two machines, and I was heavily involved in that. But the vast majority of the surgery will still go down to Vancouver. The Prince George catchment area is anything between 1,200 and 1,700 kilometres from Vancouver. So there is no comparison with 70 miles to Galway or two hours to Dublin on the train.

Would you be concerned that, in the current economic climate, the eight designated cancer services will be adequately resourced? This has been raised in the context in particular of University Hospital Galway.

The resourcing for the cancer programme is prioritised and ringfenced at UHG. We have superb facilities in Galway for breast cancer services. There is a superb breast cancer team there. They now have five breast cancer surgeons working out of Galway. The team of professionals there is as good as you would find anywhere in the world. I am happy that money will continue to be ring-fenced for the cancer service.

How near are the eight designated centres to complying with HIQA’s quality standards in terms of facilities and services?

I have no doubt that we have made tremendous progress across the centres. Some of the issues in this area that have been raised previously were about having the documentation to prove that we were doing the things we were doing. I think by and large there has been a dramatic improvement in how these services are organised. Galway, for instance, essentially achieves 100% for both the targeted waiting times for the urgent and non-urgent cases, as does CUH. We had some temporary problems in the Mater because they were renovating to put in an extra mammography machine.
We are seeing a very dramatic increase in the number of very low risk women who are being referred to the symptomatic breast clinics. These women are at comparable risk to women who would go to BreastCheck. They probably reflect women who are anxious to get access to mammography, and if they are not eligible for BreastCheck there is no other way they can get a mammogram in the public system. That has put a bit of a strain on the system but we are managing. We are working with the GPs to try and be sure that referral is appropriate. Most of these women are young, between 30 and 34 on average. Many of these women have minimal symptoms, they don’t have lumps or anything like that but are just seeking a mammogram. It is perhaps partly a reflection of increased awareness around breast cancer risk and also a lot of the recent publicity, particularly negative publicity.

Earlier this year, you said it could take many years before the cancer service improvements being implemented would impact on survival rates for some cancers. Can you explain this?

Demonstrating improved outcomes in breast cancers can take many years, given that the average survival rates are very long. You will see continuous improvement over years but it takes years in any breast cancer environment to show survival improvements because you have to wait a number of years for those survivals to become apparent. It’s a statistical thing. Survival rates have been improving and they have been improving for the last decade. The problem is they have been improving everywhere else in the world so our relative position on the league table has not changed that much. Improvements in survival rates in Ireland with breast cancer will hopefully continue and accelerate.

In terms of safety and diagnosis errors in cancer, is our error rate any higher than in other countries and will it improve?

The processes that are in place for running the symptomatic clinics are based on the best international standards that will give you the lowest possible number of rates. In other words, if you do it the way everybody says you should do it you will get the lowest rates possible and that is what we are achieving. And that means triple assessment and all the other components involved, which are now in place. A lot of the misdiagnoses occurred for the very reason that the correct processes were previously not in place. There is, however a baseline false positive and false negative rate that no centre in the world can get below due to the subjective nature of diagnostics. But our goal is to be as low as we can possibly be. There are international norms that we would expect to meet and are meeting.

In terms of the world class cancer service we aspire to and that the Minister for Health talks about, when do you think we will reach that level?

I think we are essentially there in terms of the staffing. Obviously there is some refining going on to put all the policies and procedures and documentation in place to have it absolutely nailed down. We have a very large cohort of trained breast cancer doctors and nurses and I think it is impressive that Ireland has achieved for breast cancer what many other countries are nowhere close to achieving. There are something of the order of 30 breast cancer surgeons in the country so all breast cancer treatment is being done by breast cancer surgeons, and that wasn’t the case before.

What is the timeline for other cancer services to move to the designated centres?

We are progressing the rectal cancer programme. We are in the final phase of discussions with the hospitals on this and the aim eventually is to concentrate this treatment in the eight centres as capacity is increased.
The national pancreatic cancer centre has been designated at St Vincent’s. We are negotiating with Vincent’s to take on the national workload by the end of the year. The prostate and lung cancer clinics will be rolling out over the next six to nine months. We are setting up rapid access centres for prostate cancer. Two have already been set up, at St James’s and UHG. We are suggesting to GPs that if they have a patients who has high risk criteria they should refer them directly to the rapid access centres rather than send them to the urology clinic, where there would be unnecessary delays. The rapid access clinics for lung cancer at the eight centres will be completed by next year, with lung cancer surgery limited to four centres.
Phase one of the new radiation oncology facilities on the St James’s and Beaumont sites will be completed at the end of next year and then there will be phase two which involves the construction of additional facilities at St James’s and Beaumont. Then you have the expansion in Cork and Galway, and satellite centres in Limerick and Waterford. All that has to be done by 2014. Generally speaking, at the rate that things get done here I am happy we are moving ahead. Overall, we are on target.

Do you think there is a need for national screening programmes for prostate and colo-rectal cancer?

There is no evidence to support national prostate screening. There is, however, strong evidence supporting colo-rectal screening. I am very supportive of this screening being introduced as is the Minister and it is a question of how quickly that can happen. There is an initiative to see if resources can be identified from within the HSE from the existing resource base.


Which services will remain at the units from where cancer surgery has moved or is moving?

All the chemotherapy centres are unchanged. We have said that from day one, and some of them will be enhanced. Chemotherapy is a closer-to-home thing because patients are getting chemo for six or nine months.
One of the features of the cancer system in Ireland, however, is that it is far too hospital - oriented. We are working with GPs to develop a community oncology programme to train and educate GPs in oncology (the medical treatment of cancer) and to enhance nursing capability in oncology care. This will enhance early diagnosis and referral.

Do you think there has been a certain amount of hysteria from the public and the media in relation to the reorganisation of cancer services?

I certainly wouldn’t describe it as hysteria. There has been a lot of concern. It has been totally distorted by the media, you know. We have closed breast cancer services in 24 hospitals now and if you were to ask the media was there any interest in revisiting all the centres that have closed…there is no story there any more, nobody’s interested.

But there have been major concerns regarding some centres.

Yes, Sligo I think was the number one…where there was a big concern. But we have done it successfully, we have proven to people that we can deliver the service. The Sligo people will hopefully in time begin to understand that it was the right decision. Ninety per cent of what is in the cancer control programme is not controversial. Maybe it’s the media’s job to find controversy but as far as I am concerned most of what we are doing is not controversial. There is huge support for the cancer strategy from the Cancer Society, from Europa Donna, from breast cancer experts. If you were to talk to the society of breast cancer surgeons in Ireland the overwhelming majority of those surgeons strongly support the cancer programme. You simply cannot provide optimal cancer care in 35 hospitals in a country the size of Ireland.

Your post as interim director is for two years and this term is coming to an end. Will you be staying on to further implement the reorganisation plan?

There is no plan in place for me to continue. Obviously I am still having some discussions with Prof Drumm and other people around the future plans for the cancer programme. The plan was always that I would get it up and running and the HSE would then recruit a permanent director for the programme. My term ends at the end of November or thereabouts. At the present time, I do not see myself continuing beyond that. I am still employed by the British Columbia Cancer Agency and the University of British Columbia, so I will go back to BC at that point.

How does the Irish health system compare to its Canadian counterpart?

The Irish system is very fragmented. I think a lot has been done to bring it together but in every country healthcare is a significant area of difficulty and political unrest sometimes, but I think Canadians are very satisfied with their healthcare system. They have universal healthcare and there are better outcomes for roughly the same amount of money spent as in Ireland. We have no private healthcare in Canada and all cancer care is in the public domain. There is no question that things are improving in Ireland – it’s a continuous process.
But there has been tremendous progress in the hospital system in Ireland. The vast majority of people who go into Irish hospitals are very happy with the care they receive. There are issues around access and the focus has been and rightly so, on improving access to care.

Do you think the proliferation of private medicine in Ireland inhibits access?

It’s not a hindrance provided there is no perverse incentive for the private system to essentially undermine the public system. But there isn’t any evidence of that.

Some would argue that that perverse incentive does exist and hinders access, leading to a run-down public system

That is the traditional view that would be expressed in Canada. There is no private medicine there because the Canadian people and successive governments would be of the view that investing in private medicine would undermine the public system. That’s why Canadians are very proud of their public system and are resistant to any attempts to privatise it. Private medicine will always exist in Ireland in my view. It’s a historical thing and a social phenomenon. I am not hearing any clamour to suggest it should be eliminated in Ireland.

Do you think Brendan Drumm and Mary Harney have a difficult job running the health service and would you ever be interested in running it if you got the chance?

I don’t want to answer hypothetical questions, but it is a difficult job, of course, to run a health service in any country. In most countries the ministry of health seems to be a poisoned chalice because it is an area where people have a lot of concern and anxiety and it tends to be politicised more than than any other aspect of services. It is a service that everybody’s exposed to and even if it is not working in a small way it becomes a very newsworthy item. If you go to any country in the world you will find if it is not on the top of the agenda it is very close to the top in terms of the political debate. Everybody wants more and better services at no increased cost.

How do you think our health services will cope given the current state of the public finances here?

I think there are bound to be challenges and I think the HSE is developing a vision of how it is going to manage, as other countries have had to manage. I have been through two recessions in Canada and out of these challenges a lot of good things can actually happen in terms of reform and sometimes it forces decisions that otherwise would not have been made.

docg  Posted: 21/08/2009 17:36

Just a small question; was the decision to have eight centres based on medical criteria and, if so, what were they? Or was the number a political decision and, if so, why, and what were the criteria? Sorry, there were actually three small questions.

patricia  Posted: 21/08/2009 20:08

My husband died from cancer on May 1st. He was diagnosed with stomach cancer in June 2008. He was doing brilliantly, the tumour was shrinking and he was coping well with the chemo. He finished his 8th cycle in March and we were waiting for his scans when he started getting severe headaches. On his 1st visit to A&E we were told they were tension headaches. ON the day he was due to have his catscan he collapsed with such severe pains in his head that even high doses of morphine took ages to work. He was admitted, when an MRI on his head came back clear were were told he would have 3 lumbar punctures to look for cancer cells. They were still having trouble controlling the pain. After only one lumbar puncture they were stopped. We were told he had viral meningitis and there was no need for any more. On the Thursday he was released and we were told he would just need to rest and let it run its course. On Sunday he had a seizure and was rushed back in. The following day he was sent for a PET scan, and on the Wednesday we were given the news that his cancer was in remission. We were over the moon. However his condition was still deteriorating, he had trouble walking, his eyesight was getting worse (one eye was turned in) He had more tests. On Easter Thursday he was transferred to Galway hospital. IT was the following tuesday before he had an MRI, his blood pressure was hitting the roof he was having seizures more often. The pain was getting worse and he was now unable to get out of bed. On Thursday we were told that the cancer had spread to the lining of his skull and that all they could do was give him a course of radiotherapy to prolong his life. It didn't work and on May 1st he passed away. My husbands chemo was wrongly given for his first 3 cycles in Galway hospital. My husband was on Cisplatin which can damage your kidneys if you do not have enough fluids during treatment and so should be given as an in-patient. My husband was given it as a day-patient and ended up with blocked kidneys and had to have stents put in both sides. After his first 3 cycles he was told they were starting another 3 straight away. However there were no beds free and ended up waiting over four weeks for his treatment in fact it was only after i got a local TD involved and contacted the head office of the HSE that he finally started his treatment. This is what you call a world class cancer service?  It took one different type of MRI to diagnose what my husband had, but because Castlebar doesn't have a permanent MRI scanner it wasn't available. As everyone knows quick treatment gives you the best chances. However my husband was left weeks between his treatments. Castlebar oncology are understaffed and overworked. The ward is too small and if you need to see a doctor you have to wait hours or not see one at all. I try not to get angry over my husbands death but when i hear stupid statements like this i boil. My husband was 3 9yrs old and never got anything worse than a cold his whole life.

tlc  Posted: 22/08/2009 18:15

Doctors in Galway have already stated they cannot treat all the patients from Sligo, Donegal, Leitrim and forall the patients they already have they don't have the beds or the staff. My aunt died recently in Sligo from breast cancer. The treatment she received was second to none. To force people from the northwest to travel to Galway when they are so ill is an absolute disgrace. This government and everyone involved in taking these services away should bow their heads in shame.

Anonymous  Posted: 25/08/2009 09:50

Oh Patricia, I am so so sorry to hear about your husband. These are the real cases that the Professor seems either not to be aware of or not to want to know about. Docg., they are important questions. I understood the criteria for 8 centres was medical but I don't know what it was based on exactly. I think it was something to do with the throughput of cases needed to keep specilaists' skilled honed and the geographic catchment, as far as I know. But as for saying we're close to world-class service - what planet is this guy on?? But then again he thinks it only take 2 hours to get from Dublin city to Sligo town, so maybe his unreal view of cancer services shouldn't be a surprise. tlc, I am sorry to hear about your aunt. Does the professor even listen to those doctors or acknowledge the overcrowding and lack of facilities for people as it is without adding more?

anony  Posted: 26/08/2009 10:40

We are and have been hoodwinked by 'spin'. The whole purpose of centralisation is to create the markets for the private investor. Canada was right to prevent the private investors to get in to the country and we need to halt the growth of the private before it is too late. This Canadian doc must think we cannot think for ourselves or is he just 'spinning' what he knows he has to say to fulfil his contract. He tells us that we will eventually see better outcomes for breast cancer but that it will take years. Of course we would have seen that anyhow as treatment becomes more advanced worldwide and filters through to Ireland. In Canada the outcomes improved by 25% when they introduced a proper screening programme. That is the main reason we will see an improvement in outcomes in this country.Just look at the amount of capital expenditure is necessary to build up the services in these 8 centres. There is no way this money is going to be available in the next 5 years and yet he tells us that it is going to happen and that the money will be available. This at the same time that the HSE is being told to cut their spending by a further 800 million euro. So now that he has dismantled the public system in so many hospitals what will the public patient have to rely on? Of course Dr. Keane has the support of the Irish Cancer Society and all the others he mentions - they have a vested interest in supporting his programme but will all the other organisations like CF and Disabilities of all kinds agree when they realise that their funding is being cut in order to satisfy the demands of the Cancer programme. Tell that to the family of an emergency victim, who dies en route to a distant hospital because the services were removed from his/her local hospital.  Yes the media has pushed the Government Spin and have accepted, without doing their own research, the spin being dished out to them on a daily basis. Anyone who tries to question the decisions being made, like in Sligo, are made to appear like terrorists by this Government. Prof. Drumm will say they have 'vested interests' and now Dr. Keane says there were other issues at stake in Sligo other than cancer.It is time for the people of Ireland to call a halt and that can be done by informing their local Government TD(s) that they must change the direction or else.

anony  Posted: 26/08/2009 20:43

Just thought this piece from the Canadian Press is interesting - perhaps there is work to do at home: Overhauling health-care system tops agenda at annual meeting of Canada's doctors By Jennifer Graham (CP) – Aug 15, 2009 SASKATOON — The incoming president of the Canadian Medical Association says this country's health-care system is sick and doctors need to develop a plan to cure it. Dr. Anne Doig says patients are getting less than optimal care and she adds that physicians from across the country - who will gather in Saskatoon on Sunday for their annual meeting - recognize that changes must be made. "We all agree that the system is imploding, we all agree that things are more precarious than perhaps Canadians realize," Doing said in an interview with The Canadian Press. "We know that there must be change," she said. "We're all running flat out, we're all just trying to stay ahead of the immediate day-to-day demands." The pitch for change at the conference is to start with a presentation from Dr. Robert Ouellet, the current president of the CMA, who has said there's a critical need to make Canada's health-care system patient-centred.

anony  Posted: 26/08/2009 20:57

Just thought I would give you another little extract from Wendell Goler at Fox News re. Canadian Health system: But Canadians also wait twice as long for non-emergency care and sometimes come to the U.S. for specialized treatment. Dr. Scott Gottlieb, a resident fellow at the conservative American Enterprise Institute, says the single-payer edifice is starting to crumble. "What you're starting to see in Canada is that it is falling apart, and you're seeing the growth of a private market for a lot of essential services," he said. That private market was born after a 2005 Canadian Supreme Court ruling ended the government's monopoly on some health care services. But since people have to pay out of pocket for them, Canada's public system is still overloaded. "The average wait time to get an appointment with a new primary care physician is 17 weeks and for specialty care it is even worse," he said. Canada lacks America's high technology, with about a third of the MRI machines per capita and far fewer specialists.

Margat  Posted: 28/08/2009 21:35

Well as far as Im concerned our cancer services are deplorable .The fact that we can even begin to think of the service in Galway as anything nearing satisfactory  is unthinkable.The hospital itself itself is a nightmare to attend for any service let alone going there when seriously ill with cancer. If u think our cancer services are nearing world class Mr Keane u have not been touched by that disease or any member of your family .Its only when going through the nightmare of the service that u rrealise how appalling it is .So quit patting yourself on the back and face reality The Cancer Service in this country is appalling.

anonymous  Posted: 29/08/2009 12:37

What planet is Keane  living  on?  There is a fantastic service in Sligo, they have multidiciplinary teams, triple assessment, Galway cannot  cope with the patients they have.  Why are there four centres in Dublin? None above the  line from Galway to Dublin!!!  This is political and nothing  will convince me otherwise,the sooner Harney and Keane are gone the better, the road to Galway is a disgrace and to expect very ill patients to travel this distance is an  outrage.

patriciad  Posted: 30/08/2009 02:18

I find it saddening and disheartening to read about the dismantling of the local breast treatment services.  Kerry General Hospital breast cancer unit saved my life so I could continue to be a parent, wife and friend to those who care about me and me them.  For a small (free) nation such as ours, how did it go so wrong?  Why are there so many suits in charge of highly educated and motivated physicians and medically qualified professionals?

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