The outlook is positive for breast cancer in Ireland

In the midst of all the economic doom and gloom here in Ireland, it is good to read a positive news story, such as Niall Hunter’s latest article in Irish Health.

In Ireland, over 2,000 women are diagnosed with breast cancer each year. However, Niall writes, the picture is far from a gloomy one, as major advances in cancer care have been made in recent years.
 
Thanks to vastly improved access to the right care at the right time for women with possible symptoms referred to the eight designated cancer centres, advances in treatments, and a national roll-out of the BreastCheck programme for women without symptoms, the picture for breast cancer in Ireland is far more positive than before.
 
Survival rates on the rise

Mortality rates are decreasing and will continue to decrease. Survival rates are on the rise and will continue to rise. More than 25,000 women are living following a breast cancer diagnosis.

Specialist breast centres

A key factor in the improving outlook for breast cancer has been the reorganisation of cancer services from a multitude of hospitals into the eight centres over the past three years. This reorganisation has helped improve access and quality of care. There are four centres in Dublin and centres in Cork, Galway, Limerick and Waterford, with a satellite centre in Donegal.
  
But what happens once you are referred by your GP to one of the eight designated breast cancer centres?
 
Mr James Geraghty is consultant breast surgeon and senior lecturer in general surgery at St Vincent’s University Hospital in Dublin, one of the eight designated centres.
 
“All breast cancer referrals are now dealt with at the eight centres,” he says.

“Once a woman is referred by her GP we ‘triage’ the referral letter into whether we believe it to be an urgent or less urgent case.”
 
“If it is urgent we try to see the patient within two weeks and the latest statistics show that this is being achieved in more than 95% of cases; 95% of non-urgent referrals would be seen within 12 weeks.

“We actually believe the latter figure is too long and the aim of the breast centres is to reduce this to six weeks. The current waiting time figure would be similar in all the centres. Patients should certainly not be fearful about possible undue delays in accessing the clinics.”
 
“When we designate it as a routine referral, it means we believe it highly unlikely that a cancer will be found. For every cancer we discover we would see between 25 and 30 patients who are benign, who have no cancer.

“The ratio previously would have been one cancer in 15 referrals but the number of patients referred to us has increased in recent years with the growing awareness of breast cancer, and we are seeing a lot more benign disease.”
 
“It’s very important for women to know that when they come to a breast cancer clinic the vast majority- 95% will turn out to have no significant problem.”
 
James Geraghty says among urgent referrals, there would be around a one in 15 chance of a breast cancer being diagnosed. He says it is very rare to find a cancer among routine referrals.
 
In urgent cases, triple assessment is used in making the diagnosis. The woman has an examination, a radiological assessment (mammogram/ultrasound) and a biopsy on the same day. The patient comes back for her result within a week.
 
With assessment of routine cases, a clinical examination is carried out and in women over 35,  a mammogram is also usually performed. In non-urgent cases where the woman is under 35, an ultrasound would usually be carried out if indicated.
 
The triple assessment process, James Geraghty points out, is extremely accurate in diagnosing cancer, and the testing for urgent and non-urgent cases is underscored by a review of the results at a multidisciplinary team meeting

“The most important quality indicator for providing excellence in care is the multidisciplinary team meeting. What this means in practice is that this is the ultimate specialist team meeting, attended by surgical, medical, radiology and pathology specialists and specialist nurses/allied healthcare workers

“When the patient comes to our clinic for an assessment and comes back for her results, in the intervening week or two, meetings are taking place between these specialists to ensure that the correct diagnosis is made and the correct treatment plan is established.”
 
“It’s important to note too that our performance is measured frequently by the independent safety body HIQA and the clinics all operate to agreed guidelines.

We constantly measure our own performance and will adjust our practices and policies where necessary, based on audit.”
 
“This is not postcode-related – the policy is that indicators in terms of access, quality and safety must be uniform across all eight centres. The care must be of the same high quality irrespective of which centre you go to.”
 
Thanks to improvements in the way care is provided in the eight centres, the picture is far from negative for a woman who has had the shock of a breast cancer diagnosis, James Geraghty stresses.
 
“Every decision that is made about the treatment plan for a patient is decided at our weekly team meeting. The type of treatment or treatments involved – surgery, chemotherapy, radiotherapy- is discussed by all the disciplines mentioned above. It s a holistic approach to patient care.”
 
According to James Geraghty, surgery is still the mainstay of care for patients with breast cancer.
 
“Decisions regarding further treatment with chemotherapy or radiotherapy are made after the surgery is carried out and once the type of cancer involved is known.”
 
“We try to give patients a sense of breast cancer not simply as a ‘black or white’ entity. It’s really not a case of being in big trouble if you have it – there are many different shades and nuances of cancer.”
 
“With a ‘good’ cancer, the survival figures are very good and it is very important for us to relay this prognosis to the patient. The results for ductal cancer in situ, which is a pre-invasive early form of cancer, are particularly good. It is extremely important to let the patient know exactly what type of breast cancer they have and if it is at an early stage, to emphasise the good news about the excellent survival rates.
 
James Geraghty explains that there are three grades of cancer used, with one being the “best” in term of prognosis and three the “worst”.
 
“The use of chemotherapy depends mainly on the nodal status – whether the glands in the armpit are involved. If they are, chemotherapy is usually indicated. The rigorous assessment we carry out on each patient will tell us what type of cancer we are dealing with; the size, the grade and whether the lymph nodes are involved.”
 
“If a woman has a small breast cancer then a mastectomy can be avoided. For patients who have breast conservation and do not need a mastectomy, radiotherapy is usually required as well as surgery.”
 
According to James Geraghty, between 45% and 50% of women who have been diagnosed with breast cancer will need a mastectomy, but this figure is variable.
 
“Whenever possible, we offer patients breast reconstruction, usually at the time of the surgery if mastectony is needed.”
 
If a woman is having chemotherapy, it will be administered in around four to six cycles separated by three-week intervals – lasting around three to four months in total. It usually involves having the drug treatment intravenously in a morning or afternoon session.

Radiation therapy is normally given in five daily sessions per week for five weeks, with each session taking only two to three minutes.
 
In a small minority of patients, all three modalities- surgery, chemotherapy and radiation therapy, may be required.
 
The side effects of chemotherapy and radiotherapy are well-documented and, James Geraghty says, can vary from patient to patient in terms of the type of effects and their severity.
 
Mr Geraghty stresses that these effects do not last – the hair will grow back and the nausea will end when the treatment ends.
 
“With radiation therapy, the side effects usually are fatigue, and there may be some slight skin changes on the breast that has been irradiated, but again, these effects do not last.”
 
“With chemotherapy, your blood count begins to return to normal within around 10 days after the treatment ends. You may feel unwell for a time afterwards but this should pass within 10 – 12 days.”
 
James Geraghty stresses that with treatments constantly improving in their effectiveness, the outlook for women diagnosed with breast cancer is on a constant upward curve.
 
“What is especially encouraging for the future is that we will as a matter of course have tailored treatments or new therapeutic agents that will specifically target cancers. These drugs will be able to target the cancer cells and not other organs. Currently, much chemotherapy has to target a wider areas than where the cancer is.”
 
“The drug Herceptin is one example of these new therapies that mainly target the cancer, and it has excellent results. Only around 25% of breast cancer patients are suitable for this drug at the moment. It has excellent results. However, it is important to stress that there will be ‘new herceptins’ coming through in the not too distant future.”
 
James Geraghty says the overall survival rate for breast cancer is continuing to improve thanks to screening detecting more cancers earlier and thanks to more effective therapies.
 
“It’s very important that people are aware of that – that the picture is in fact quite positive. Also, it’s very likely that we will see even greater strides in survival once the full effects of standardised care for breast cancer across Ireland take effect. This is already starting to happen but should bear full fruit in terms of survival statistics within the next five to 10 years.”