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Australia, Fiji, New Zealand, Tonga

Latest Research Publications from Oceania

Cocker F, Chien Yee K, Palmer AJ, de Graaff B
Increasing incidence and mortality related to liver cancer in Australia: time to turn the tide.
Aust N Z J Public Health. 2019; 43(3):267-273 [PubMed] Related Publications
OBJECTIVE: Assess national and jurisdictional incidence and mortality trends for primary liver cancer in Australia.
METHODS: Analysis of Australian Cancer Incidence and Mortality data published in 2017 by the AIHW. Age-standardised rates (ASR) for 1982 to 2014/2015. Piecewise linear regression was used to assess temporal trends. For the purposes of comparison, data were also extracted for all cancers with greater burdens of disease (lung, colorectal, breast, prostate, pancreatic, and brain cancers and melanoma of the skin).
RESULTS: Since 1982, the average annual percentage change (AAPC) for ASR incidence of liver cancer was 4.858% (95%CI 4.558-5.563). This marked a 306% increase from 1.822/100,000 persons (95%CI 1.586-2.058) in 1982 to 7.396/100,000 persons (95%CI 7.069-7.723) in 2014. AAPC for ASR mortality was 3.013% (95%CI 2.448-3.521): an increase of 184% from 2.323/100,000 persons (95%CI 2.052-2.594) in 1982 to 6.593/100,000 (95%CI 6.290-6.896) in 2015. ASR incidence and mortality were highest in the NT (12.607/100,000 persons), VIC (8.229/100,000) and NSW (7.798/100,000). In comparison to the other selected cancers, higher AAPC for both incidence and mortality of liver cancer were observed.
CONCLUSION: Incidence and mortality associated with liver cancer have increased substantially in the past three decades, in contrast to the improved outcomes observed for many other cancers. Jurisdictional incidence rates reflect higher prevalence of hepatitis B and C. Implications for public health: In the context of Australian cancer prevention and care programs, liver cancer is an outlier. Strategies to mitigate risk factors and improve surveillance of liver health for at-risk groups are urgently required.

Laaksonen MA, Arriaga ME, Canfell K, et al.
The preventable burden of endometrial and ovarian cancers in Australia: A pooled cohort study.
Gynecol Oncol. 2019; 153(3):580-588 [PubMed] Related Publications
OBJECTIVE: Evidence on the endometrial and ovarian cancer burden preventable through modifications to current causal behavioural and hormonal exposures is limited. Whether the burden differs by population subgroup is unknown.
METHODS: We linked pooled data from six Australian cohort studies to national cancer and death registries, and quantified exposure-cancer associations using adjusted proportional hazards models. We estimated exposure prevalence from representative health surveys. We then calculated Population Attributable Fractions (PAFs) with 95% confidence intervals (CIs), accounting for competing risk of death, and compared PAFs for population subgroups.
RESULTS: During a median 4.9 years follow-up, 510 incident endometrial and 303 ovarian cancers were diagnosed. Overweight and obesity explained 41.9% (95% CI 32.3-50.1) of the endometrial cancer burden and obesity alone 34.5% (95% CI 27.5-40.9). This translates to 12,800 and 10,500 endometrial cancers in Australia in the next 10 years, respectively. The body fatness-related endometrial cancer burden was highest (49-87%) among women with diabetes, living remotely, of older age, lower socio-economic status or educational attainment and born in Australia. Never use of oral contraceptives (OCs) explained 8.1% (95% CI 1.8-14.1) or 2500 endometrial cancers. A higher BMI and current long-term MHT use increased, and long-term OC use decreased, the risk of ovarian cancer, but the burden attributable to overweight, obesity or exogenous hormonal factors was not statistically significant.
CONCLUSIONS: Excess body fatness, a trait that is of high and increasing prevalence globally, is responsible for a large proportion of the endometrial cancer burden, indicating the need for effective strategies to reduce adiposity.

Hall MT, Smith MA, Lew JB, et al.
The combined impact of implementing HPV immunisation and primary HPV screening in New Zealand: Transitional and long-term benefits, costs and resource utilisation implications.
Gynecol Oncol. 2019; 152(3):472-479 [PubMed] Related Publications
BACKGROUND: In response to emergent evidence, many countries are transitioning from cytology-based to HPV screening. We evaluated the impact of an upcoming transition on health outcomes and resource utilisation in New Zealand.
METHODS: An extensively validated model of HPV transmission, vaccination, natural history and cervical screening ('Policy1-Cervix') was utilised to simulate a transition from three-yearly cytology for women 20-69 years to five-yearly HPV screening with 16/18 genotyping for women 25-69 years, accounting for population growth and the impact of HPV immunisation. Cervical cancer rates, resources use (test volumes), costs, and test positivity rates from 2015 to 2035 were estimated.
FINDINGS: By 2035, the transition to HPV screening will result in declines in cervical cancer incidence and mortality rates by 32% and 25%, respectively, compared to 2018. A potentially detectable 5% increase in cervical cancer incidence due to earlier detection is predicted for the year of transition. Annual numbers of women screened will fluctuate with the five-year screening interval. Cytology volumes will reduce by over 80% but colposcopy volumes will be similar to pre-transition rates, and program costs will be reduced by 16%. A 9% HPV test positivity rate is expected in the first round of HPV screening (2019-2023), with 2.7% of women referred for colposcopy. Transitioning from cytology to primary HPV cervical screening could avert 149 cancer cases and 45 deaths by 2035.
CONCLUSION: Primary HPV screening and vaccination will reduce cervical cancer and resources use. A small transient apparent increase of invasive cancer rates due to earlier detection may be detectable at the population level, reflecting the introduction of a more sensitive screening test. These findings can be used to inform health services planning and public communications surrounding program implementation.

Velentzis LS, Smith MA, Simms KT, et al.
Pathways to a cancer-free future: A protocol for modelled evaluations to maximize the future impact of interventions on cervical cancer in Australia.
Gynecol Oncol. 2019; 152(3):465-471 [PubMed] Related Publications
OBJECTIVE: Australia's HPV vaccination and HPV-based cervical screening programs are changing the landscape in cervical cancer prevention. We aim to identify areas which can make the biggest further impact on cervical cancer burden. This protocol describes the first stage of a program of work called Pathways-Cervix that aims to generate evidence from modelled evaluations of interventions across the cervical cancer spectrum.
METHODS: Based on evidence from literature reviews and guidance from a multi-disciplinary Scientific Advisory Committee (SAC), the most relevant evaluations for prevention, diagnosis and treatment were identified.
RESULTS: Priority evaluations agreed by the SAC included: increasing/decreasing and retaining vaccination uptake at the current level; vaccinating older women; increasing screening participation; methods for triaging HPV-positive women; improving the diagnosis of cervical intraepithelial neoplasia (CIN) and cancer; treating cervical abnormalities and cancer; and vaccinating women treated for CIN2/3 to prevent recurrence. Evaluations will be performed using a simulation model, Policy1-Cervix previously used to perform policy evaluations in Australia. Exploratory modelling of interventions using idealised scenarios will initially be conducted in single birth cohorts. If these have a significant impact on findings then evaluations with more realistic assumptions will be conducted. Promising strategies will be investigated further by multi-cohort simulations predicting health outcomes, resource use and cost outcomes.
CONCLUSIONS: Pathways-Cervix will assess the relative benefits of strategies and treatment options in a systematic and health economic framework, producing a list of 'best buys' for future decision-making in cervical cancer control.

Parente P, Chan BA, Hughes BGM, et al.
Patterns of care for stage III non-small cell lung cancer in Australia.
Asia Pac J Clin Oncol. 2019; 15(3):93-100 [PubMed] Related Publications
Stage III non-small cell lung cancer (NSCLC) makes up a third of all NSCLC cases and is potentially curable. Despite this 5-year survival rates remain between 15% and 20% with chemoradiation treatment alone given with curative intent. With the recent exciting breakthroughs in immunotherapy use (durvalumab) for stage III NSCLC, further improvements in patient survival can be expected. Most patients with stage III NSCLC present initially to their general practitioner (GP). The recommended time from GP referral to first specialist appointment is less than 14 days with treatment initiated within 42 days. Our review found that there is a shortfall in meeting these recommendations, however a number of initiatives have been established in Australia to improve timely and accurate diagnosis and treatment patterns. The lung cancer multidisciplinary team (MDT) is critical to consistency of evidence-based diagnosis and treatment and can improve patient survival. We aimed to review current patterns of care and clinical practice recommendations for stage III NSCLC across Australia and identify opportunities to improve practice in referral, diagnosis and treatment pathways.

Magnusson M, Beath K, Cooter R, et al.
The Epidemiology of Breast Implant-Associated Anaplastic Large Cell Lymphoma in Australia and New Zealand Confirms the Highest Risk for Grade 4 Surface Breast Implants.
Plast Reconstr Surg. 2019; 143(5):1285-1292 [PubMed] Related Publications
BACKGROUND: The epidemiology and implant-specific risk for breast implant-associated (BIA) anaplastic large cell lymphoma (ALCL) has been previously reported for Australia and New Zealand. The authors now present updated data and risk assessment since their last report.
METHODS: New cases in Australia and New Zealand were identified and analyzed. Updated sales data from three leading breast implant manufacturers (i.e., Mentor, Allergan, and Silimed) were secured to estimate implant-specific risk.
RESULTS: A total of 26 new cases of BIA-ALCL were diagnosed between January of 2017 and April of 2018, increasing the total number of confirmed cases in Australia and New Zealand to 81. This represents a 47 percent increase in the number of reported cases over this period. The mean age and time to development remain unchanged. The implant-specific risk has increased for Silimed polyurethane (23.4 times higher) compared with Biocell, which has remained relatively static (16.5 times higher) compared with Siltex implants.
CONCLUSIONS: The number of confirmed cases of BIA-ALCL in Australia and New Zealand continues to rise. The implant-specific risk has now changed to reflect a strong link to implant surface area/roughness as a major association with this cancer.

Callander E, Bates N, Lindsay D, et al.
Long-term out of pocket expenditure of people with cancer: comparing health service cost and use for indigenous and non-indigenous people with cancer in Australia.
Int J Equity Health. 2019; 18(1):32 [PubMed] Free Access to Full Article Related Publications
BACKGROUND: Indigenous Australians diagnosed with cancer have poorer survival compared to non-Indigenous Australians. We aim to: 1) identify differences by Indigenous status in out-of-pocket expenditure for the first three-years post-diagnosis; 2) identify differences in the quantity and cost of healthcare services accessed; and 3) estimate the number of additional services required if access was equal between Indigenous and non-Indigenous people with cancer.
METHODS: We used CancerCostMod, a model using linked administrative data. The base population was all persons diagnosed with cancer in Queensland, Australia (01JUL2011 to 30JUN2012) (n = 25,553). Each individual record was then linked to their Admitted Patient Data Collection, Emergency Data Information System, Medicare Benefits Schedule (MBS), and Pharmaceutical Benefits Scheme (PBS) records (01JUL2011 to 30JUN2015). We then weighted the population to be representative of the Australian population (approximately 123,900 Australians, 1.7% Indigenous Australians). The patient co-payment charged for each MBS service and PBS prescription was summed for each month from date of diagnosis to 36-months post-diagnosis. We then limited our model to MBS items to identify the quantity and type of healthcare services accessed during the first three-years.
RESULTS: On average Indigenous people with cancer had less than half the out-of-pocket expenditure for each 12-month period (0-12 months: mean $401 Indigenous vs $1074 non-Indigenous; 13-24 months: mean $200 vs $484; and 25-36 months: mean $181 vs $441). A stepwise generalised linear model of out-of-pocket expenditure found that Indigenous status was a significant predictor of out of pocket expenditure. We found that Indigenous people with cancer on average accessed 236 services per person, however, this would increase to 309 services per person if Indigenous people had the same rate of service use as non-Indigenous people.
CONCLUSIONS: Indigenous people with cancer had lower out-of-pocket expenditure, but also accessed fewer Medicare services compared to their non-Indigenous counterparts. Indigenous people with cancer were less likely to access specialist attendances, pathology tests, and diagnostic imaging through MBS, and more likely to access primary health care, such as services provided by general practitioners.

Murphy M, Dowling A, Thien C, et al.
A feasibility study of the Nativis Voyager
CNS Oncol. 2019; 8(1):CNS31 [PubMed] Free Access to Full Article Related Publications
AIM: Evaluation of the Nativis Voyager
MATERIALS & METHODS: A total of 15 patients with rGBM were treated with one of two Voyager ultra-low radio frequency energy cognates: A1A or A2HU. Safety and clinical utility were assessed every 2-4 months.
RESULTS: Median overall survival was 8.04 months in the A1A arm and 6.89 months in the A2HU arm. No serious adverse events associated with Voyager were reported. No clinically relevant trends were noted in clinical laboratory parameters or physical exams.
CONCLUSION: The data suggest that the Voyager is safe and feasible for the treatment of rGBM.

Whiteman DC, Neale RE, Aitken J, et al.
When to apply sunscreen: a consensus statement for Australia and New Zealand.
Aust N Z J Public Health. 2019; 43(2):171-175 [PubMed] Related Publications
INTRODUCTION: Cancers of the skin are the most common cancers in humans, with Australia and New Zealand having the world's highest incidence. Primary prevention campaigns advise people to apply sunscreen to exposed body sites when outdoors. However, despite growing evidence that cumulative sub-erythemal exposures cause mutational damage, and trial data demonstrating benefit from daily sunscreen use, current policies do not consider the hazards of incidental (everyday) sun exposure. Thus, a Sunscreen Summit was convened to review the evidence and update the policies for people living in Australia and New Zealand.
RESULTS: After reviewing the benefits and risks of sunscreen application, the policy group concluded that people living in Australia and New Zealand should be advised to apply sunscreen to the face/head/neck and all parts of the body not covered by clothing on all days when the ultraviolet index is forecast to reach three or greater, irrespective of their anticipated activities. For planned outdoors activities, sunscreen should be used alongside other sun protection measures.
CONCLUSIONS: People living in Australia and New Zealand are now advised to apply sunscreen every day when the UV index is predicted to reach 3 or above. Implications for public health: Increased use of sunscreen as part of the daily routine to reduce incidental sun exposure will lead to decreased incidence of skin cancer in the future.

Scott OW, Tin Tin S, Bigby SM, Elwood JM
Rapid increase in endometrial cancer incidence and ethnic differences in New Zealand.
Cancer Causes Control. 2019; 30(2):121-127 [PubMed] Related Publications
PURPOSE: Endometrial cancer accounts for 3.9% of all female cancers globally, and its incidence appears to be increasing in women under 40 years of age. This paper investigated ethnic-specific trends in endometrial cancer across different age groups in New Zealand.
METHODS: Women who were diagnosed with endometrial cancer between 1996 and 2012 were identified from the New Zealand Cancer Registry. Annual age-standardized incidence and mortality rates were calculated for each ethnicity (Māori, Pacific, and non-Māori non-Pacific) in four age groups (< 40, 40-49, 50-74, and 75 +). The estimates were adjusted for hysterectomy. Joinpoint regression analysis was used to assess trends over time and annual percentage changes (APCs) were estimated.
RESULTS: Between 1996 and 2012, age-standardized incidence rates increased in all women and significantly in the < 40, 40-49, and 50-74 age groups (APC 9.22, 3.56, and 1.65 respectively). Incidence rates were highest in Pacific women and increased most rapidly in those under 50 years of age (APC 9.36). Conversely, age-standardized mortality rates decreased in all women and significantly in the 50-74 and 75 + age groups (APC - 5.25 and - 5.06 respectively), with the highest rate observed in Pacific women.
CONCLUSION: Pacific women had the highest incidence of endometrial cancer and the trend was increasing, particularly in young women. This could be attributed, at least in part, to a high and increasing rate of obesity in these women and should be explored in future research.

Emery JD, Murray SR, Walter FM, et al.
The Chest Australia Trial: a randomised controlled trial of an intervention to increase consultation rates in smokers at risk of lung cancer.
Thorax. 2019; 74(4):362-370 [PubMed] Free Access to Full Article Related Publications
BACKGROUND: International research has focused on screening and mass media campaigns to promote earlier patient presentation and detect lung cancer earlier. This trial tested the effect of a behavioural intervention in people at increased risk of lung cancer on help-seeking for respiratory symptoms.
METHODS: Parallel, individually randomised controlled trial. Eligible participants were long-term smokers with at least 20 pack-years, aged 55 and above. The CHEST intervention entailed a consultation to discuss and implement a self-help manual, followed by self-monitoring reminders to encourage help-seeking for respiratory symptoms. The control group received a brief discussion about lung health. Both groups had baseline spirometry. Telephone randomisation was conducted, 1:1, stratified Medical Research Council (MRC) dyspnoea score and general practice. Participants could not be blinded; data extraction and statistical analyses were performed blinded to group assignment. The primary outcome was respiratory consultation rates.
RESULTS: We randomised 551 participants (274 intervention, 277 control) from whom the primary outcome was determined for 542 (269 intervention, 273 control). There was a 40% relative increase in respiratory consultations in the intervention group: (adjusted rates (95% CI) intervention 0.57 (0.47 to 0.70), control 0.41 (0.32 to 0.52), relative rate 1.40 (1.08 to 1.82); p=0.0123). There were no significant differences in time to first respiratory consultation, total consultation rates or measures of psychological harm. The incremental cost-effectiveness ratio was $A1289 per additional respiratory consultation.
CONCLUSIONS: A behavioural intervention can significantly increase consulting for respiratory symptoms in patients at increased risk of lung cancer. This intervention could have an important role in primary care as part of a broader approach to improve respiratory health in patients at higher risk.
TRIAL REGISTRATION NUMBER: Australian New Zealand Clinical Trial Registry (1261300039 3752). This was registered pre-results.

Sherman SM, Bartholomew K, Denison HJ, et al.
Knowledge, attitudes and awareness of the human papillomavirus among health professionals in New Zealand.
PLoS One. 2018; 13(12):e0197648 [PubMed] Free Access to Full Article Related Publications
BACKGROUND: Human papillomavirus (HPV) is a common sexually transmitted infection that is implicated in 99.7% of cervical cancers and several other cancers that affect both men and women. Despite the role that HPV plays in an estimated 5% of all cancers and the evolving role of HPV vaccination and testing in protecting the public against these cancers, preliminary research in New Zealand health professionals suggest knowledge about HPV may not be sufficient.
METHODS: A total of 230 practice nurses, smear takers and other clinical and laboratory staff who attended a range of training events completed a cross-sectional survey between April 2016 and July 2017. The survey explored four broad areas: demographics and level of experience, HPV knowledge (general HPV knowledge, HPV triage and test of cure (TOC) knowledge and HPV vaccine knowledge), attitudes towards the HPV vaccine and self-perceived adequacy of HPV knowledge.
RESULTS: The mean score on the general HPV knowledge questions was 13.2 out of 15, with only 25.2% of respondents scoring 100%. In response to an additional question, 12.7% thought (or were unsure) that HPV causes HIV/AIDS. The mean score on the HPV Triage and TOC knowledge questions was 7.4 out of 10, with only 9.1% scoring 100%. The mean score on the HPV vaccine knowledge questions was 6.0 out of 7 and 44.3% scored 100%. Only 63.7% of respondents agreed or strongly agreed that they were adequately informed about HPV, although 73.3% agreed or strongly agreed that they could confidently answer HPV-related questions asked by patients. Multivariate analyses revealed that knowledge in each domain predicted confidence in responding to patient questions. Furthermore, the number of years since training predicted both HPV knowledge and Triage and TOC knowledge.
DISCUSSION: Although overall level of knowledge was adequate, there were significant gaps in knowledge, particularly about the role of HPV testing in the New Zealand National Cervical Screening Programme. More education is required to ensure that misinformation and stigma do not inadvertently result from interactions between health professionals and the public.

Harman J, Govender S, Simpson J, Benjamin B
A New Method for Partial Breast Reconstruction: 3-Year New Zealand Experience.
Plast Reconstr Surg. 2019; 143(1):49-52 [PubMed] Free Access to Full Article Related Publications
In New Zealand, oncoplastic surgery is common, but partial breast reconstruction presents challenges for radiation therapy targeting. Tissue rearrangement creates ambiguity when targeting the tumor bed, with resultant overestimation of treatment volumes. Thus, adoption of advanced methods of radiation therapy have been hindered. This pilot study describes use of a novel three-dimensional implant that provides a scaffolding for tissue ingrowth during partial breast reconstruction and delineates the tumor bed more precisely to assist radiation planning and mammographic surveillance. After informed consent, 15 women were implanted with the three-dimensional bioabsorbable implant. The device was sutured to the tumor bed during lumpectomy, and tissue flaps were mobilized and attached to the implant. Visualization of the marker and radiation treatment volumes were recorded and compared. The implant provided volume replacement and helped to maintain breast contour. Cosmetic outcomes were excellent; no device- or radiation-related complications occurred. One patient had a postoperative hematoma that resolved after percutaneous drainage; there were no postoperative infections. Three-year follow-up shows no tumor recurrences and no untoward effects. When compared to conventional radiation targeting, use of the implant showed that a greater than 50 percent reduction in treatment volume was possible in some cases. Three-year mammograms show no significant artifact, normal tissue ingrowth, and minimal fibrosis. This study describes a method of oncoplastic breast reconstruction using an implantable device that marks the site of tumor excision and provides for volume replacement with tissue ingrowth. Patients tolerated it well, and radiation therapy planning, positioning, and treatment were facilitated.

Serna-Higuita LM, Harrison SL, Buttner P, et al.
Modifiable Risk-factors for Keratinocyte Cancers in Australia: A Case-control Study.
Acta Derm Venereol. 2019; 99(4):404-411 [PubMed] Related Publications
Keratinocyte cancer is the most common malignancy in Caucasians. The aim of this study was to investigate risk-factors responsible for development of keratinocyte cancer in Australia. A case-control study was conducted, including 112 cases of squamous cell carcinoma (SCC), 95 cases of basal cell carcinoma (BCC) and 122 controls. Freckling during adolescence (SCC: odds ratio (OR) 1.04, p < 0.01; BCC: OR 1.05, p < 0.01), propensity to sunburn (SCC: OR 2.75, p = 0.01, BCC: OR 2.68 p = 0.01) and high cumulative sun-exposure (SCC: OR 2.43, p = 0.04; BCC: OR 2.36 p = 0.04) were independent risk-factors for both SCC and BCC. This study provides further evidence that a sun-sensitive phenotype and excessive sun-exposure during adulthood contribute to the risk of developing keratinocyte cancer. Wearing a hat, long-sleeved shirts, and sunscreen did not significantly reduce the risk of keratinocyte cancer in this study.

Elliott BM, Douglass BR, McConnell D, et al.
Cutaneous squamous cell carcinoma: predictors of positive and close margins and outcomes of re-excision in Northland, New Zealand.
N Z Med J. 2018; 131(1487):23-29 [PubMed] Related Publications
BACKGROUND: Non-melanoma skin cancer (NMSC) is the most commonly diagnosed and costly cancer in Australasia. Cutaneous squamous cell carcinoma (cSCC) accounts for approximately 25% of NMSC. A better understanding of predictors of close and positive margins following surgical excision will help guide treatment.
METHODS: A retrospective study was carried out of all primary cSCC histologically diagnosed in Northland, New Zealand in 2015. The cohort was identified by searching the regional pathology database. The primary outcome of interest was positive and close (≤1mm) margin rate following surgical excision and factors influencing them. Secondary outcomes of interest were outcomes of re-excisions.
RESULTS: A total of 1,040 cSCC were identified in 890 unique patients and 825 lesions were surgically excised. Increased odds of positive margin on surgical excision was found with increased tumour thickness (OR 1.56, 95% CI 1.24-1.96), tumours from the head and neck (OR 2.78, 95% CI 1.33-5.80) and those excised in primary care (OR 2.20, 95% CI 1.07-4.52). Increased odds of close margins was found in females (OR 2.01, 95% CI 1.3-3.2) and excision in primary care (OR 2.44 95% CI 1.5-3.98). Residual tumour was present in 13 (31.7%) patients with positive margins and 0 patients with close margins.
CONCLUSIONS: Lesions of the head and neck, those removed in primary care and with increased tumour thickness were more likely to have positive margins following surgical excision. Close margins were associated with excision in primary care and female gender. The value of re-excising tumours with close margins remains uncertain.

Yang X, Wang S, Trangle SS, et al.
Investigation of Different Molecular Weight Fucoidan Fractions Derived from New Zealand
Mar Drugs. 2018; 16(11) [PubMed] Free Access to Full Article Related Publications
Fucoidan, a sulfated polysaccharide extracted from brown seaweeds, has been shown to possess various antioxidant, anticoagulant, antiviral, and anticancer functions. In this study, we focused on low molecular weight fucoidan (LMWF) which was extracted from New Zealand

Kim L, Nguyen N, Singhal N, et al.
Application of stereotactic body radiotherapy in advanced pancreatic cancers in Australia.
J Med Radiat Sci. 2019; 66(1):54-61 [PubMed] Free Access to Full Article Related Publications
INTRODUCTION: The majority of pancreatic cancers present locally advanced and carry a high mortality rate. Treatment is challenging, with mixed data suggesting use of chemotherapy alone or in combination with radiotherapy. The use of radiotherapy has previously been limited due to lack of ability to deliver radiation to the tumour mass without causing significant toxicity to surrounding organs. Stereotactic body radiotherapy (SBRT) allows delivery of higher biologically equivalent dose in a shorter treatment duration. We sought to investigate the safety and application of this technique in our centre.
METHOD: We enrolled 27 patients from 2015, identified as locally advanced unresectable with histologically confirmed, non-metastatic, pancreatic adenocarcinoma. All patients had endoscopically inserted fiducial markers and where possible concurrent chemotherapy was administered. Dose schedules ranged from 25 to 42 Gy in 5 or 3 fractions.
RESULTS: With an overall median follow up of 9 months (range, 3-32.7), the median survival was 11.6 months. Of those alive at 1 year, the local control rate was 67%. Six patients had Grade 3 toxicity, and other six had Grade 2 toxicity. None had Grade 4 or above toxicity. The most common symptom recorded was fatigue.
CONCLUSION: SBRT for locally advanced pancreatic cancer is technically complex but feasible in a high volume centre. SBRT is unique, allowing safe delivery of high radiation dose resulting in good local control and decreases treatment time making it an attractive option for patients with unresectable pancreatic cancer.

Toliman PJ, Kaldor JM, Badman SG, et al.
Performance of clinical screening algorithms comprising point-of-care HPV-DNA testing using self-collected vaginal specimens, and visual inspection of the cervix with acetic acid, for the detection of underlying high-grade squamous intraepithelial lesions in Papua New Guinea.
Papillomavirus Res. 2018; 6:70-76 [PubMed] Free Access to Full Article Related Publications
The performance of different clinical screening algorithms comprising point-of-care HPV-DNA testing using self-collected vaginal ('V') specimens, and visual inspection of the cervix with acetic acid (VIA) was evaluated in Papua New Guinea. Women aged 30-59 years provided V specimens that were tested at point-of-care using the Xpert HPV Test (Cepheid, Sunnyvale, CA). A clinician-collected cervical ('C') specimen was then collected for point-of-care Xpert testing, and liquid-based cytology (LBC). Following this, VIA examination was conducted, blind to HPV test results, and ablative cervical cryotherapy provided if indicated. Detection of high-grade squamous intraepithelial lesion (HSIL) by LBC was the reference standard used to evaluate clinical screening algorithms. Of 1005 women, 36 had HSIL+. Xpert HPV Test performance using V specimens (sensitivity 91.7%, specificity 87.0%, PPV 34.0%, NPV 99.3%) was superior to VIA examination alone (51.5%, 81.4%, 17.5%, 95.6% respectively) in predicting underlying HSIL+. A screening algorithm comprising V specimen HPV testing followed by VIA examination had low sensitivity (45.5%) but comparable specificity, PPV and NPV to HPV testing alone (96.3%, 45.5%, 96.3% respectively). A 'test-and-treat' screening algorithm based on point-of-care HPV testing of V specimens had superior performance compared with either VIA examination alone, or a combined screening algorithm comprising HPV testing plus VIA.

Smith CA, Hunter J, Delaney GP, et al.
Integrative oncology and complementary medicine cancer services in Australia: findings from a national cross-sectional survey.
BMC Complement Altern Med. 2018; 18(1):289 [PubMed] Free Access to Full Article Related Publications
BACKGROUND: Individuals living with and beyond a cancer diagnosis are increasingly using complementary therapies and medicines (CM) to enhance the effectiveness of cancer treatment, manage treatment-related side effects, improve quality-of-life, and promote self-efficacy. In response to the increasing use and demand for CM by cancer patients, interest in the implementation of Integrative Oncology (IO) services that provide CM alongside conventional cancer care in Australia and abroad has developed. The extent that cancer services in Australia are integrating CM is uncertain. Thus, the aim of this study was to identify IO services in Australia and explore barriers and facilitators to IO service provision.
METHODS: A national, cross-sectional survey of healthcare organisations was conducted in 2016. Organisations in the public and private sectors, including not-for-profit organisations that provided cancer care in hospital or community setting, were included.
RESULTS: A response rate of 93.2% was achieved (n = 275/295). Seventy-one organisations (25.8%) across all states/territories, except the Northern Territory, offered IO albeit in a limited amount by many. Most common IO services included massage, psychological-wellbeing, and movement modalities in hospital outpatient or inpatient settings. There were only a few instances where biological-based complementary medicine (CM) therapies were prescribed. Funding was often mixed, including patient contributions, philanthropy, funding by the organisation, and volunteer practitioners. Of the 204 non-IO providers, 80.9% had never provided any IO service. Overwhelmingly, the most common barrier to IO was a lack of funding, followed by uncertainty about patient demand, choice of services, and establishing such services. Less-common barriers were a lack of evidence, and support from oncologists or management. More funding, education and training, and building the evidence-base for CM were the most commonly suggested solutions.
CONCLUSION: IO is increasingly being provided in Australia, although service provision remains limited or non-existent in many areas. Mismatches appear to exist between low IO service provision, CM evidence, and high CM use by cancer patients. Greater strategic planning and policy guidance is indicated to ensure the appropriate provision of, and equitable access to IO services for all Australian cancer survivors.

Bishop D, Patel D, Heath A
A New Zealand case of nasal myiasis involving Lucilia cuprina (Diptera: Calliphoridae).
N Z Med J. 2018; 131(1484):68-70 [PubMed] Related Publications
A case of nasal myiasis that occurred in February 2017 in the Northland region was the first involving L. cuprina naturally-acquired in New Zealand.

Wilson LF, Baade PD, Green AC, et al.
The impact of changing the prevalence of overweight/obesity and physical inactivity in Australia: An estimate of the proportion of potentially avoidable cancers 2013-2037.
Int J Cancer. 2019; 144(9):2088-2098 [PubMed] Related Publications
Globally, 39% of the world's adult population is overweight or obese and 23% is insufficiently active. These percentages are even larger in high-income countries with 58% overweight/obese and 33% insufficiently active. Fourteen cancer types have been declared by the World Cancer Research Fund to be causally associated with being overweight or obese: oesophageal adenocarcinoma, stomach cardia, colon, rectum, liver, gallbladder, pancreas, breast, endometrium, ovary, advanced/fatal prostate, kidney, thyroid and multiple myeloma. Colon, postmenopausal breast and endometrial cancers have also been judged causally associated with physical inactivity. We aimed to quantify the proportion of cancer cases that would be potentially avoidable in Australia if the prevalence of overweight/obesity and physical inactivity in the population could be reduced. We used the simulation modelling software PREVENT 3.01 to calculate the proportion of avoidable cancers over a 25-year period under different theoretical intervention scenarios that change the prevalence of overweight/obesity and physical inactivity in the population. Between 2013 and 2037, 10-13% of overweight/obesity-related cancers in men and 7-11% in women could be avoided if overweight and obesity were eliminated in the Australian population. If everyone in the population met the Australian physical activity guidelines for cancer prevention (i.e. engaged in at least 300 min of moderate-intensity physical activity per week), an estimated 2-3% of physical inactivity-related cancers could be prevented in men (colon cancer) and 1-2% in women (colon, breast and endometrial cancers). This would translate to the prevention of up to 190,500 overweight/obesity-related cancers and 19,200 inactivity-related cancers over 25 years.

Snoswell CL, Whitty JA, Caffery LJ, et al.
Direct-to-consumer mobile teledermoscopy for skin cancer screening: Preliminary results demonstrating willingness-to-pay in Australia.
J Telemed Telecare. 2018; 24(10):683-689 [PubMed] Related Publications
Introduction Internationally, teledermoscopy has been found to have clinical and economic efficacy. This study aims to identify the attributes of a mobile teledermoscopy service that consumers prefer. This preliminary study was set within a broader randomised control trial (RCT) investigating the effectiveness of direct to consumer mobile teledermoscopy. Methods We undertook a discrete choice experiment (DCE). The DCE comprised 24 choice sets, divided into in two blocks of 12. For each choice set, respondents were asked to make discrete choices between two opt-out choices and two skin cancer screening service options described by seven attributes. A mixed logit model was used to estimate preferences for skin cancer screening services. Consumer preferences weights were used to calculate marginal willingness-to-pay (WTP) for skin cancer screening services. Results The DCE was completed by 113 consumer respondents. Consumers' preference for dermatologist involvement in their diagnosis, increased accuracy, and reduced excisions were all statistically significant in driving choice between service models. Consumers preferred having a professional involved in their skin cancer screening, rather than performing a self-examination. Consumers were only WTP $1.18 to change from a GP visit to mobile teledermoscopy (diagnosis using a phone camera). However, they were WTP $43 to have their results reviewed by a dermatologist rather than a GP, and $117 to increase the chance of detecting a melanoma if it was present from 65-75% to 95%. Conclusion Skin cancer screening services which are delivered by health professionals, rather than skin self-examination, are preferred by consumers. Consumers were willing to pay for their preferred skin cancer screening method, especially if a dermatologist was involved.

Petelin L, James PA, Trainer AH
Changing landscape of hereditary breast and ovarian cancer germline genetic testing in Australia.
Intern Med J. 2018; 48(10):1269-1272 [PubMed] Related Publications
Federal funding for germline genetic testing in hereditary breast and ovarian cancer (HBOC) was recently introduced. Germline testing for HBOC under Medicare Benefits Schedule items 73296/73297 can be requested by any specialist, whereas the previous state- and territory-funded testing was limited to those operating within a familial cancer service. The impact of this decentralisation of HBOC testing on health and economic outcomes is uncertain, primarily as it has potential to significantly disrupt the clinical framework that generated the evidence used to justify clinical implementation of the Medicare Benefits Schedules.

Nguyen AD, Wong W, Beydoun N, et al.
Radiotherapy patterns of care for stage I and II non-small cell lung cancer in Sydney, Australia.
J Med Imaging Radiat Oncol. 2019; 63(1):131-141 [PubMed] Related Publications
INTRODUCTION: Curative radiotherapy is guideline treatment for inoperable patients of good performance status with Stage I & II Non-Small Cell Lung Cancer (NSCLC). The aim of this study was to evaluate radiotherapy patterns of care in these patients, the reasons for palliative treatment and the proportion of patients suitable for curative stereotactic ablative body radiotherapy (SABR).
METHODS: Electronic oncology databases at three institutions were queried to retrieve data on patients with inoperable Stage I & II NSCLC seen in radiation oncology clinics between 1/1/2008 and 31/12/2014. Suitability for SABR was defined as peripheral tumours less than 5 cm in size. Factors associated with curative treatment were determined using univariate and multivariate analyses.
RESULTS: Three-hundred-and-twelve patients were identified of whom 178 (57%) received curative radiotherapy, 58 (19%) palliative radiotherapy and 76 (24%) no radiotherapy. The main reason for receiving palliative rather than curative treatment was COPD or poor pulmonary function (26%). Method of diagnosis (P = 0.031), Simplified Comorbidity Score (P = 0.003), ECOG performance status (P = 0.016), FEV1% (P = 0.040), treating institution (P < 0.0001) and time period (P = 0.016) were associated with curative radiotherapy on multivariate analysis. In patients with T1-2N0M0 NSCLC, 19 (31%) who did not receive treatment and 7 (21%) who underwent palliative radiotherapy were technically and clinically suitable for SABR.
CONCLUSION: Only 57% of patients with Stage I-II NSCLC were treated with curative radiotherapy. Patient factors were the predominant reason for palliative treatment, however, treating institution also played a role. A considerable proportion of patients who underwent palliative or no radiotherapy were suitable for SABR treatment.

Tin Tin S, McKeage MJ, Khwaounjoo P, et al.
Incomplete uptake of EGFR mutation testing and its impact on estimation of mutation prevalence in patients with non-squamous NSCLC: A population-based study in New Zealand.
Cancer Epidemiol. 2018; 57:24-32 [PubMed] Related Publications
BACKGROUND: Epidermal Growth Factor Receptor (EGFR) mutation testing is recommended for patients with non-squamous non-small cell lung cancer (NSCLC) but not all eligible patients get tested, which may bias the mutation prevalence estimated. This study aims to examine trends in the uptake of EGFR mutation testing in patients with non-squamous NSCLC in New Zealand; to develop a composite metric that quantifies the influences of demographic and clinico-pathological factors on the testing uptake; and to estimate the prevalence of EGFR mutation if all patients were tested.
METHODS: This population-based study involved all patients who were diagnosed with non-squamous NSCLC in four health regions in New Zealand between January 2010 and December 2015. Eligible patients were identified from the New Zealand Cancer Registry and information on EGFR mutation testing was obtained through linkage to TestSafe, a clinical information sharing service, and laboratory records.
RESULTS: Of 2701 eligible patients, 1059 (39.2%) were tested for EGFR mutation. The testing prevalence increased (3.7% in 2010 to 64.6% in 2014) and the influences of demographic and clinic-pathological factors decreased from 2010 to June 2014, and remained stable afterward. Of the tested patients, 229 (21.6%) were mutation positive with a decreasing trend observed from 2010 (43.8%) to June 2014 (16.8%). The best-fit log-linear model estimated the prevalence of EGFR mutation, if all patients were tested, as 15.5% (95% CI: 13.2%-18.0%).
CONCLUSION: The methods described here allowed a more accurate estimation of the prevalence of EGFR mutation.

Martini A, Morris JN, Jackson HM, Ohan JL
The impact of parental cancer on preadolescent children (0-11 years) in Western Australia: a longitudinal population study.
Support Care Cancer. 2019; 27(4):1229-1236 [PubMed] Related Publications
PURPOSE: Australian population data regarding the number and sociodemographic characteristics of children affected by a parent's cancer are not currently available. Moreover, predictions that this population is increasing have not been tested. This study provides data on the number and sociodemographic characteristics of parents with cancer and their young children (aged 0-11 years) in the state of Western Australia, and investigates whether long-term trends in this population have increased over time.
METHODS: Linked administrative data were used to describe parents with malignant cancer and their children aged 0-11 years at the time of diagnosis between 1982 and 2015 in Western Australia. Parents and children were described overall and by year of diagnosis and sociodemographic characteristics. A Poisson regression was used to investigate trends in the number of children affected, accounting for population growth. Incidence counts of parental cancer characteristics were included.
RESULTS: Between 1982 and 2015, 15,938 parents were diagnosed with a malignant cancer, affecting 25,901 children. In 2015, 0.28% of children in Western Australia experienced a parent's diagnosis. The number of children affected increased over time; however, this was accounted for by population growth. The majority of families lived in regional areas and were of high socioeconomic status. Older children and older parents most frequently experienced parental cancer. Skin and breast cancer were the most common diagnoses.
CONCLUSIONS: A substantial number of families are affected by parental cancer. Results can guide intervention development and delivery to children of different developmental stages, and inform decisions regarding resource allocation and health service accessibility.

Klaver R, Coe JR
Barriers to healthcare for female patients in Papua New Guinea.
BMJ Case Rep. 2018; 2018 [PubMed] Related Publications
A 25-year-old woman presented to hospital in the remote highlands of Papua New Guinea (PNG) with a 3-year history of increasing abdominal distension, amenorrhoea and syncope. Ultrasound showed a large unilocular ovarian cyst. During her work-up, she was found to be HIV positive. She was treated with antiretroviral therapy, and once her CD4 count improved, she underwent a laparotomy and removal of the ovarian cyst with immediate improvement in symptoms. PNG has high levels of HIV particularly in young women and children.

Rollin A, Ridout B, Campbell A
Digital Health in Melanoma Posttreatment Care in Rural and Remote Australia: Systematic Review.
J Med Internet Res. 2018; 20(9):e11547 [PubMed] Free Access to Full Article Related Publications
BACKGROUND: The melanoma incidence and mortality rates in rural and remote communities are exponentially higher than in urban areas. Digital health could be used to close the urban/rural gap for melanoma and improve access to posttreatment and support care services.
OBJECTIVE: The aim of this review was to understand how digital health is currently used for melanoma posttreatment care and determine the benefits for Australian rural and remote areas.
METHODS: A systematic search of PubMed, Medline, PsycINFO, and Scopus was conducted in March 2018. Findings were clustered per type of intervention and related direct outcomes.
RESULTS: Five studies met the inclusion criteria, but none investigated the benefits of digital health for melanoma posttreatment care in rural and remote areas of Australia. Some empirical studies demonstrated consumers' acceptance of digital intervention for posttreatment care. The findings did not take into consideration individual, psychological, and socioeconomic factors, even though studies show their significant impacts on melanoma quality of aftercare.
CONCLUSIONS: Digital interventions may be used as an adjunct service by clinicians during melanoma posttreatment care, especially in regions that are less-resourced by practitioners and health infrastructure, such as rural and remote Australia. Technology could be used to reduce the disparity in melanoma incidence, mortality rates, and accessibility to posttreatment care management between urban and rural/remote populations.

Rice S, Zhou L, Martin R
Epidemiology of melanoma in situ in New Zealand: 2008-2012.
N Z Med J. 2018; 131(1482):73-79 [PubMed] Related Publications
AIM: The incidence of melanoma in situ varies throughout the world. It is associated with excellent outcomes, however many of those untreated will go on to develop invasive melanoma with a worse prognosis. There is no previously published data on melanoma in situ (MIS) in New Zealand. Further information is needed to enable better understanding of the disease spectrum.
METHODS: De-identified data were obtained from the New Zealand Cancer Registry (NZCR) by way of computerised search for MIS diagnosis. A separate search was performed to identify all patients with invasive melanoma. World Health Organization standard population was used for calculating age standardised rates.
RESULTS: There was a trend to increasing cases of MIS, but a relative plateauing of invasive melanoma. The number of cases for MIS overtook invasive melanoma in 2012. Overall, men had a significantly higher incidence compared to women. Incidence rates varied markedly between different regions of the country.
CONCLUSIONS: This paper provides new information about the epidemiology of MIS in New Zealand and its relevance to clinical practice. Public education strategies may be beginning to show effect with the goal of increasing prevention and earlier detection and treatment to enable decrease in melanoma mortality.

Hanna MZ, Kalev-Zylinska ML, Jackson SR, et al.
Distinctive features of polycythaemia vera in New Zealand Polynesians.
N Z Med J. 2018; 131(1482):38-45 [PubMed] Related Publications
AIM: The aim of this study was to examine a potential ethnic disparity in the phenotype of polycythaemia vera (PV) between New Zealand European and Polynesian patients.
METHOD: A retrospective review of medical records was conducted at Middlemore Hospital to identify adult patients with PV diagnosed between 1987 and 2007. Data extracted included diagnostic criteria, ethnicity, age, complications and survival.
RESULTS: Eighty-eight adult patients with PV were identified during 1987-2007, 49 (55.7%) were Europeans and 36 (40.9%) Polynesians. The most striking finding was that Polynesian patients presented almost 14 years younger than Europeans (mean age of 54 years versus [vs] 68, respectively; P<.001). The white cell and platelet counts were higher in Polynesians compared with Europeans (mean white cell count of 22x109/L vs 13x109/L; mean platelet count of 648x109/L vs 512x109/L, respectively; P<.05 for both). The rate of JAK2 V617F mutation in Polynesians was 96%, equivalent to other large cohorts of European patients. The rates of long-term complications were comparable between Polynesians and Europeans, but the predicted impact on life expectancy was more severe for Polynesians.
CONCLUSION: New Zealand Polynesian patients present with a distinctive PV phenotype. Their younger age at presentation suggests a different risk factor profile or a higher genetic susceptibility. We hope our observations initiate larger epidemiological and genetic studies to help elucidate the cause.

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