Cancer Services

I want to raise the call for women to be told their breast density before they are told they have cancer. Almost half of all women have dense breasts and it is important to note that dense breasts are normal. Dense breast tissue is made up of glands and fibrous tissue. However, on a mammogram, cancer shows up as white but so too does breast density. Looking for a cancerous tumour in a dense breast is like looking for a ball of cotton in a snow storm. While having dense breasts does not mean one will automatically have cancer, it does carry an increased risk of developing breast cancer. Having high breast density can mask cancer and the denser the tissue, the whiter the mammogram. High breast density cannot be detected by a physical examination. It is identified solely through medical imaging. In Ireland, breast density is not currently recorded during BreastCheck screening mammograms. In the words of Laurna, "Breast density isn't just words". It is information about a woman's body that belongs to her. It is a question of ethics and personal autonomy and knowing one's breast density matters. It is critical information that will inform shared consent and shared decision-making and could help guard against the harmful effects of a potentially delayed diagnosis of breast cancer. Most diagnostic and hospital screening mammogram facilities use 3D Tomosynthesis equipment that gives a breast density reading. There is no reason not to pass this information on to women. We heard from several women at a presentation in the audiovisual room recently who had all been diagnosed with breast cancer and all of them said that they had never been told their breast density and the condition may have prevented earlier diagnosis. In fact, we heard from one woman who knew her breast density and although she got a clear mammogram result four months earlier, she took the decision to investigate further and discovered that she had a stage one invasive lobular carcinoma. Evan was lucky and after surgery she was in the clear, with no evidence of the disease. She said that if she had not known that she had dense breasts, she would have not gone for further tests and would, therefore, not have known that she had breast cancer. Many women are not so lucky. Lobular breast cancer is the second most common subtype of breast cancer, accounting for 15% of all breast cancers annually. Treating advanced breast cancer requires significantly more intensive, invasive and costly medical interventions. As Laurna put it, "Breast density isn't just words". It affects husbands, partners, children and the wider family. The human cost is enormous. The financial costs of being out of work, the costs to the State of extensive surgeries and treatments and the mental health costs are all avoidable. Countries like the USA, Canada, France and Austria inform women of their breast density. Margaret asked why the HSE and the Government are denying women this basic information about their bodies. These women have asked that the Government would stop using mixed messages and stop using women's anxiety as a reason to withhold this clinically relevant information. They said that this is playing with women's lives. They have a petition with over 10,000 signatures, so this is not a small group. Like myself, a lot of women have never heard of dense breasts. I first heard about it only last year. The fact is that when many women first hear about it, usually it is when they are being told that they have cancer. Then they have to go through extensive treatment or for some, like Hannah, stage four cancer, with no good result at the end.

I thank the Deputy for the opportunity to discuss the important matter of breast density notification. I am taking this issue on behalf of the Minister for Health, Deputy Carroll MacNeill. Enhancing Ireland’s population screening programmes is a priority for the Minister. These programmes are a vital component of our health services. Dense breast tissue is common. Around half of all women have dense breasts and it is a normal variation in breast tissue. Breast density is one of several factors that can influence breast cancer risk. It is very important to say, however, that having dense breasts does not mean someone will develop breast cancer. High levels of breast density can make mammograms more difficult to interpret in some women. However, breast density alone does not automatically mean that further imaging is required. Decisions about additional imaging are made on an individual basis by the clinical team as part of a woman's assessment and diagnosis. BreastCheck mammograms remain the best screening test available for population breast screening for women aged between 50 and 69. It can save lives by finding many cancers early, often before symptoms develop. It is important to know that mammography detects the majority of breast cancers, including in women with dense breasts. Consideration of any changes to Ireland’s screening programmes is facilitated through established evidence-driven protocols. The national screening advisory committee, NSAC, is the expert group that advises on any proposed changes to Ireland’s screening programmes. At the request of the committee, the Health Information and Quality Authority, HIQA, has commenced a health technology assessment, HTA, to consider proposals for the expansion of the BreastCheck programme. This review comprises three distinct components. One is the proposed extension of the age range eligibility to those aged between 45 and 49. Another is the extension of age range to those aged from 70 to 74. The third element is the potential introduction of a standardised breast density notification. HTAs facilitate the assessment of relevant evidence on the effects and consequences of healthcare technologies or programmes. They seek to guide decisions regarding the appropriate use of technology and efficient allocation of resources. They involve a multidisciplinary assessment of clinical, economic, ethical, legal and societal perspectives that may be impacted by the introduction of a new technology or programme. HTAs are, by their nature, time intensive and rigorous processes that must be afforded the necessary time to complete. This is particularly relevant in the context of the BreastCheck HTA, which, as I said, is considering three distinct areas, including the potential reporting of breast density. It is expected that the final HIQA HTA report on all three elements will be submitted to the NSAC before the end of 2027. Once received, the committee will consider the findings and make a recommendation to the Minister for Health. The introduction or expansion of any new screening service requires careful consideration, particularly when we are considering all the clinical, ethical, societal, legal and economic perspectives. The Minister wishes to develop services that are clinically effective and have positive health outcomes. This is particularly relevant in the context of significant differences in international clinical opinion on the incorporation of breast density notification into screening. This emphasises the need for an evidence-led approach to ensure that any decision serves the best interests of Irish women.

I thank the Minister of State for answering this question on behalf of the Minister for Health. The departmental response states that BreastCheck mammography remains the best screening option because it detects the majority of breast cancers, including in women with dense breasts. However, what the women who presented to us are saying is that in some cases, the cancer has grown to a point where it takes extensive treatment or, for some, it is too late for treatment. Siobhán told us that if she had known she had dense breasts, her 7 cm tumour would have been found earlier because she would have insisted on having other forms of breast checks, as she would have known that her dense breasts could be masking cancer, which it was. She could have had a lumpectomy and avoided a mastectomy. She could have had avoided chemotherapy and had the tumour detected earlier so that it would not have spread to her auxiliary nodes. In some cases, BreastCheck clinics use older 2D mammogram equipment but software packages are available that can be used to upgrade these older units. The fact that women are not being told their breast density is nothing short of inequality for women. We are not telling them exactly what is happening with their bodies. I have written to the Minister asking for a meeting with these women who have dense breasts and are suffering with breast cancer. These women will never be the same after a breast cancer diagnosis, especially a delayed diagnosis. Some women will be told too late about their cancer diagnosis and will have to struggle with stage four cancer. They have been on this campaign for ten years and unfortunately some of them are no longer with us. This is going on a long time and it is not just about the physical scars for some. They will have mental scars from this. While I welcome the age range eligibility and the potential report on breast density, in terms of a woman's right to have the information on her body, the potential should be turned into the reality of telling women of their breast density.

I thank the Deputy for raising her concerns and those of many of the women, families and advocacy groups she mentioned with regard to this issue. We share those concerns. They are being taken seriously by Government. The discussion about breast density notification is important because it relates directly to women's confidence in the screening programme and access to information about their health. At the same time, the Minister for Health has a responsibility to ensure that any changes to the national screening programme are informed by robust clinical evidence and supported by the appropriate clinical pathways. The Deputy will be aware that the health technology assessment under way will examine the potential introduction of a standardised breast density notification as part of the wider review of the BreastCheck programme due to be reported late next year. I acknowledge many women want swifter progress and I understand that from the Deputy's perspective. However, as a Government we are ensuring that we can continue to get the best possible outcomes for women and ensure that women have confidence in the care they receive. There is a timing issue and maybe that is what we differ on, but the objective is aligned, which is that Irish women receive the highest standard of screening information and care possible. That is the effort the Minister and her Department are working towards. I will take back the concerns raised by the Deputy.