Prescription for Trouble

By Stephen McKinley

DUBLIN — In 2001, two Irish women, Kathryn Byrne and Helen Geraghty were diagnosed with breast cancer.

Byrne, a public relations executive in Dublin, and Geraghty, who runs a guest house in Salthill, on the outskirts of Galway city, have both been successfully treated. But the story each tells of her recovery illustrates an astonishing disparity in Ireland’s health service, particularly with cancer treatment.

Cancer facilities in Ireland are as good as the most advanced in the U.S. But the farther away from the capital a patient lives, the more varied the level and sophistication of the treatment available — although there are no hard numbers available on the relative success of treatment outside of Dublin, and much of the evidence is anecdotal.

“Someone has said that there is a 75 percent better survival chance because of being located in Dublin,” Byrne said recently.

This statistic was contested by health officials in Dublin, but one doctor said that while it could be difficult to determine exact figures, in the west and northwest of Ireland, treatment with radiation fell and invasive major surgery rose. It indicated, said oncologist Dr. John Kennedy, that the farther one lived from Dublin, one’s access to the most up-to-date treatment lessened.

Questions are being asked about this disparity in Ireland, especially given the Celtic Tiger’s recent era of prosperity. Spending on health has increased from about euro 2.9 billion in 1996 to more than euro 5.3 billion in 2001, but the best health care, particularly for cancer treatment, depends increasingly on where one lives in what some have come to call Ireland’s “post code lottery.”

Dr. Kennedy, an oncologist at St. James’ Hospital, treated Kathryn Byrne. He has no illusions about the scale of the problem.

“The west and northwest have a small, dispersed population with no city and cancer services are poorly developed,” he said. “It is generally true that the farther you are from a radiation facility, the more likely it is that you will have a mastectomy.”

In the end, both Byrne and Geraghty had to have mastectomies. However, their personal stories indicate what a difference is made by living close to the best treatment centers in Dublin.

It was in October 2001 that Byrne noticed, “just by chance,” a lump the size of a golf ball under her arm. She went to her doctor immediately.

“He sent me straight away for a mammogram,” Byrne said. The news was bad. “I had a needle biopsy and the results came back malignant.”

“But my experience was very positive,” she said. “It was positive from a health-care perspective, the doctors were very good, the nurses were very good. I put that down to Dr. John Kennedy. Even the receptionists knew your first name when you came in. It’s amazing.”

Increasingly, cancer specialists in the U.S. have come to stress the importance of what they call integrated treatment: cancer is best defeated by intensive care with facilities from chemotherapy and radiation to surgery to aftercare all concentrated in one physical location.

All of Byrne’s treatment was in central Dublin, within easy access.

“If the weather was good, I walked,” said Byrne, a bright, professional woman, who was fortunate enough to live close to St Luke’s where she had her chemotherapy.

In Galway, Helen Geraghty was preparing for her daughter’s wedding in spring 2001, when she, too, discovered that she had a lump in her breast.

Geraghty, a spirited woman in her early 50s, was relaxing in her living room as she recounted her story. She picked up a photograph of herself from before her cancer treatment.

“Before I lost my hair,” she explained, “I was blond with straight hair. And look at me now!” she laughed, gesturing to her hair, which has grown back dark and curly.

“I found a lump under my arm,” she continued. “My doctor sent me to see the specialist in Galway. He said he’d see me the following week, and sent me home that evening.”

Byrne’s diagnosis and surgery in Dublin was lightening fast by comparison.

She explained: “I went into hospital Friday, had the tests on Monday and the mastectomy on Tuesday.”

In Galway, Geraghty had the misfortune of learning that her lump was malignant, almost by accident.

“I went back to my doctor, and he was on the phone and he was really angry,” she said. “I overheard him ask, ‘Who did the histology?’ I knew then that the news was bad. He came in and said, ‘I am so sorry to have to break the news this way,’ because he knew that I had overheard how he had been on the phone.”

At first Geraghty was told that she only needed radiation treatment, not chemotherapy. This diagnosis was later changed and she needed both.

“I had to wait several weeks,” she said. “Chemo can be had in Galway, but I had to go to Dublin for radiation.” This was the start of her harrowing treatment experience: frequent traveling to Dublin for many weeks, virtually putting her life on hold. The distance is about three hours, comparatively short compared to distances in the U.S., but on poorer roads in Ireland, this is a considerable drive.

In Dublin, Kathryn Byrne had decided to shave off her hair, “so that it was my decision, rather than just losing it” to the chemotherapy.

Her treatment experience was tough, but was alleviated by the concentration of excellent counseling and aftercare services at St. James’.

“I had four doses of chemo every three weeks for 12 weeks,” she said. “Radiation treatment was 30 days over six weeks. A friend of mine had cancer seven years ago. She had a recurrence last year, and she said facilities were much improved.”

Perhaps the most shocking aspect of Geraghty’s experience was when she arrived in Dublin for her first radiation treatment.

The radiation must be targeted with pinpoint accuracy on the affected area: the area is usually marked so that a radiologist can focus the treatment on the exact spot. Although a St. James’ doctor said her account could not be accurate, Geraghty affirmed that Dublin area patients had their breasts marked with felt tip pens. Those who like herself were traveling from much farther, received a small but permanent tattoo.

“People down in the West had to be tattooed, whereas women in Dublin could be marked with ink. That was really, not frightening, but distressing,” she said.

A Dublin doctor responded: “It’s up to the patient. Tattoos are used when patients do not want to have to go through being re-marked when the initial markings fade.” But Geraghty insisted that she was not offered a choice.

Geraghty’s trauma was increased by the news that her daughter had been diagnosed with multiple sclerosis, after first being misdiagnosed in Galway. She herself began the weekly trip to Dublin and back.

“So I would go up Monday morning to Dublin for my radiation, and came back Friday night,” she said.

Others from the west and northwest were even worse off.

“I met a lovely woman from Donegal, and the North Western Health Board subsidized a little aircraft for patients like her, from Donegal town,” Geraghty remembered. “But she still lived 50 miles from the aircraft.”

Political agendas

Why Ireland has not developed better regional cancer treatment facilities, despite massively increased health spending, is relatively simple, said Dr. Kennedy. And it is not just a case of a small, formerly underdeveloped country only now coming to terms with providing an adequate health care system to all its citizens.

“The primary problem in this small country is not a lack of money but that the agenda is political rather than medical,” he explained from his cool, green office in St. James’. “Our political system encourages health care facilities and benefits to be treated by politicians and their constituents as political footballs.”

Thus, in the Midlands, representatives in Tullamore and Athlone have been fighting with each other over the location of a new cancer treatment facility, resulting in deadlock. The money for the new service is there, but nothing has progressed: both Byrne and Geraghty mentioned the Tullamore-Athlone tussle: it is clearly a well-known story of mismanagement and politicking.

A measure of how jealously guarded localized hospital facilities are in Ireland is seen from the strong showing of independent candidates in the recent general election: single issue so-called “hospital candidates” were elected in at least six constituencies, where there is strong local opinion in favor of improving health care, especially cancer treatment facilities.

In March, Taoiseach Bertie Ahern made a visit to a hospital in Waterford, where his vehicle was attacked by cancer survivors and their angry family members: they were demanding a cancer scanner unit for that region.

“A lot of the people out here were cancer sufferers or their families,” an eyewitness told reporters at the time. “One woman told me that she would be prepared to do jail for what she had done today, if it would get a radiotherapy unit for the southeast.”

Such strong emotions are understandable: even with rising health care costs, rural populations are loathe to see facilities located away from their part of the country.

A treatment facility centralized in the Midlands would have made Geraghty’s experience much easier, she said, even if she still had to travel some distance from her home in Galway, for all of her treatment.

Mary Power, another cancer patient in the southeast of the country, needed radiation treatment, again only available in Dublin. She said she was faced with a choice of traveling a daily round trip of 200 miles or finding a place to stay in Dublin: neither option was attractive while in the throes of radiation-induced nausea.

Nor will all Irish health insurers pay for a place to stay — Geraghty’s insurer would not pay for a bed and breakfast accommodation, although she did find a place to stay at the hospital.

“It was terribly tough. Every Monday morning, with your little suitcase, heading for Dublin for the week,” she said. “And at night, being alone. That’s what cancer is for me, going up there on my own every night.”

Her family, including her famous husband, stood by her as best they could (Geraghty’s husband, Tom, was the winning goalkeeper in the 1964, ’65 and ’66 All-Ireland).

“It’s like a third world country at times,” Geraghty said. “My immune system was shot because of the chemo, and I ended up one Sunday night on a stretcher in a hospital corridor, for several hours. I had pleurisy.”

Aftercare

After her treatment in Dublin, Kathryn Byrne was able to avail of yet another service that most patients in the west and northwest have never heard of: Arc House.

Standing for Aftercare Research Counseling, the ARC Cancer Support Center on North Dublin’s Eccles Street is a voluntary organization and registered charity.

The house offers support to people affected by cancer and their loved ones. This support is holistic and complements the primary medical treatment with education and psychological care. Services in ARC House are free of charge.

“ARC is brilliant,” Byrne said. “I also attend a support group for young women with breast cancer.” Friends and family members of cancer sufferers can also attend. Geraghty in Galway had never heard of it, although a similar project has just recently been opened in Cork, the first one outside of Dublin.

Seeking answers

So what is the answer to Ireland’s cancer treatment lottery? Dr. Kennedy is well-placed to comment. Like many of his colleagues in the field of cancer treatment, he trained in the U.S. in the Johns Hopkins Oncology Center in Baltimore for 11 years. He offered a comparison with the U.S. system, where people often travel much farther for treatment.

“It is appropriate to expect people to travel some distance to get expert therapy,” he said. “This is a small island. But access to specialist services is limited and should be improved.” He reiterated that what stands in the way of better integrated services for those outside Dublin is politics.

Kennedy recommends the siting of several regional centers for cancer treatment, and also suggests that an island-wide approach be taken. Distance should not be an adequate complaint if proper roads and infrastructure were provided, he said.

“The natural hinterland for Donegal is Northern Ireland and cancer services there should be integrated, say, for radiation therapy, with Belfast,” he said. “Services in Sligo, Leitrim, Mayo and Roscommon should be integrated with Galway. The problem for patients in these areas is access. Proper transport infrastructure is as big a cause of problems with health care delivery as inadequate health care infrastructure.”

Several private attempts have been made to augment Ireland’s regional cancer treatment deficit. One that attracted media attention in recent years was launched by pop singer Ronan Keating. Keating launched a mobile breast cancer screening unit campaign in April 2001, aimed at providing three mobile units for Ireland, although the service has been criticized for the length of time it has taken to become fully operational.

Keating was moved to launch the service after his mother, Marie, died of breast cancer in 1998. But the central aim of the service is more to raise awareness of breast cancer generally than to offer a solution to the regional deficit.

More recently, a U.S.-based health care provider visited the West of Ireland in June of this year, in order to take an audit of cancer diagnosis facilities. The company, whose representatives declined to speak to the press until they had made further study of the region, is hoping to provide a basic, private-sector service where women can be rapidly examined, tested and screened for breast cancer, after which both patient and results would be passed in to the regular Irish health care system.

These solutions, however, barely address the real problem of integrated cancer treatment facilities, which, experts say, ought to be concentrated at a handful of central locations around Ireland, the way they already exist in the St. James’ model in Dublin.

Kennedy is reticent about the prospects of this happening.

“There’s no perfect health care system,” he said. “I believe the U.S. system at its root is dominated by the economic imperative. That’s good for those who can pay but bad for those who can’t, though I prefer a system with financial imperatives rather than political ones. It’s more predictable.”

For women like Kathryn Byrne, a cancer diagnosis is bad enough, but at least living in the Dublin environs apparently presents a better chance of achieving wellness than for those living outside the capital. Helen Geraghty’s experience indicates that the trauma of a cancer diagnosis can only be exacerbated by poor regional facilities, while politicians argue over the location of cancer treatment facilities.

Geraghty is angry about her treatment, but not bitter. She recalled one important factor that drove her to complete her treatment and become well again: the knowledge that her daughter was suffering from multiple sclerosis.

“Treatment is the luck of the draw, even in the choice of doctor,” she said. “And you know, you get over cancer at 54, when you know your daughter has M.S. at 28.”