In 1997 a regional Director of Cancer Services was appointed supported by a multi-disciplinary steering committee and the Dept. of Public Health.

In formulating the Cancer Plan it was decided to concentrate on the eight main cancers which effect the population. These cancers are: lung, colorectal, breast, prostate, cervix, skin, oesophagogastric, and blood. In addressing these common cancers consideration has been given to how the Board can become more self-sufficient in providing the appropriate treatment within the region. Where supra-regional services are at present required then it was proposed that this Board would establish supra-regional links which will best meet the needs of those patients.

2. Epidemiology of Cancer in the South East

Cancer is the most common cause of death in adults under 65 years in the South Eastern Health Board region. There were 215 deaths in people aged under 65 from cancer in 1995. Cancer is also a significant cause of death in those aged > 64 years accounting for 20% of deaths in this age group. A total of 579 people aged > 64 years died of cancer in 1995.

Figure 4.1 shows cancer is the most common cause of premature death in the region.

Figure 4.1 Major Causes of Premature Death (Ages 15 - 64 years) - SEHB, 1995

Source: Public Health Information System (Version 2)

The standardised death rate from cancer for those aged less than 65 years was 80 per 100,000 population in the South Eastern Health Board. This lies in the mid range of values between health board regions, as outlined in Figure 4.2.

Figure 4.2 Standardised Death Rate for all Cancers for population < 65 years* for Ireland and the Health Boards, 1991-1995

In particular Ireland experiences higher death rates in men from colorectal and prostate cancer, and in women from cancer of the trachea, bronchus and lung, cancer of the colorectum and cancer of the breast.

As outlined, cancer is a major cause of premature death in middle age. This is highlighted by the shorter life expectancy experienced in middle age by Irish men and women compared to their European partners.

There are a number of major cancers which cause death in men and women. In men the most common cancer that causes death is cancer of the trachea, bronchus or lung, accounting for 20% of deaths. The next most common cause of cancer death is cancer of the large intestine i.e. the colon or rectum accounting for 13% of cancer deaths. This is followed by cancer of the prostate at 12% of deaths and cancer of the stomach and oesophagus at 9% of deaths. Lymphatic and haemopoietic cancers account for 7% of deaths in men. Non melanomatous skin cancer is the most common cancer to occur however it rarely causes death and only accounts for 1% of deaths in men.

Figure 4.3 shows the proportions of the various fatal cancers in men.

Figure 4.3 Proportion of Deaths in Males due to Main Cancers - SEHB (1991-1995)

Source: Public Health Information System (Version 2)

The most common cause of cancer death in women is cancer of the breast (17% of deaths). This is followed by cancer of the trachea, bronchus and lung accounting for 15% of cancer deaths in women. Cancer of the large bowel i.e. colon and rectum accounts for 12% of cancer deaths in women. Lymphatic and haemopoietic cancers account for 10% of cancer deaths and 8% of cancer deaths are caused by cancer of the stomach and oesophagus. Cancer of the cervix, while only accounting for 2% of cancer deaths in women is important because of its preventability. As in men non-melanomatis skin cancer accounts for 1% of deaths in women. Figure 4.4 shows the proportions of fatal cancers in women.

Figure 4.4 Proportion of Deaths in Females due to Main Cancers - SEHB (1991- 1995)

Source: Public Health Information System (Version 2)

Cancer causes a significant proportion of years of potential life lost. It accounts for 12% of the years of life prematurely lost in men under 65 years of age and 27% years of life lost for women. Lung cancer causes approximately 4% of premature years of life lost in men and 3% in women. Breast cancer is the major cause of premature years of life lost by cancer in women, causing 10% of the years lost under 65 years old in women.

Figure 4.6 shows the standardised death rate for the major cancers for the last fifteen years in women in the South Eastern Health Board, and Ireland as a whole.

The trends in the South East are similar to Ireland except for differences in lung cancer and prostate cancer deaths.

Figure 4.5  Average Standardised Death Rate for Males in Ireland and SEHB for Selected Cancers per 100,000 population

Source: Public Health Information System (Version 2)

Figure 4.6  Average Standardised Death Rate for Females in Ireland and SEHB per 100,000 Population (for Selected Cancers)

Source: Public Health Information System (Version 2)

Figure 4.7 Standardised Death Rate (1991-1995) for All Neoplasms for Males and Females per 100,000 population with 95% Confidence Intervals

Source: Public Health Information System (Version 2)

The South Eastern Health Board Cancer Plan2 addresses each of the major cancers identified above, describes the prospects for prevention of each cancer, the nature of diagnosis and treatment applicable to each cancer, the current existing services for Board residents and recommends how the service can be developed to achieve quality and equity. It also addresses the need to develop oncology services, radiotherapy services, palliative care services, histopathology and cytology services within the Board area.

The Plan emphasises the need to strengthen health promotion, as the burden of illness due to cancer within the South East would be reduced if life style factors could be changed. It is estimated that cigarette smoking causes 90% of lung cancer and probably one third of all cancers. Alcohol and diet contribute to approximately one third of cancers while the risk of skin cancer is reduced by adequate protection from the sun. The Plan recommends that the Board must act to reduce smoking, and highlights two specific initiatives; the development of a smoke free policy throughout the health board and the support of smoking cessation interventions by general practitioners.

The Plan highlights the importance of links with tertiary centres and the ongoing need to improve links between primary and secondary care. It emphasises the need to encourage and support voluntary support groups in each local area and to develop comprehensive information and consumer feed back communication with patients and their families.

A major priority for cancer services, identified in the 1996 public health report, was the development, adoption and audit of evidence based effective treatment protocols for cancer diagnoses and treatment. The cancer plan proposed the development of the services structured to achieve best medical outcomes as evidenced by scientific research. One of the responsibilities of the Director of Cancer Services, the hospital co-ordinators and the steering committee is to promote the use of treatment and care protocols and the auditing of the region's cancer services on an ongoing basis.

Guidelines for care and treatment of various cancers are being developed nationally, and their implementation will be facilitated locally. Detailed audit and outcome information will be required by professionals undertaking clinical audit. Within the South East the development of clinical information systems, audit support systems and linkages to epidemiological data will be essential for this purpose. These developments will require the support of an audit facilitator in each general hospital, information technology support staff and public health epidemiological and statistical support.

It is recommended that:

The implementation of the plan be prioritised and additional resources sought as part of the 1999 Service Plan.

Clinical guidelines and audit systems be initiated by clinicians in the region, and these be supported and resourced by additional funding.