Document 21512

CANCERmatters
N e w s l et t e r o f t h e We s t e r n A u s t r a l i a n C l i n i c a l O n co l o g y G r o u p
Welcome to the 9th edition of Cancer Matters A newsletter on all clinical aspects of cancer control for Western Australian health professionals
Volume 9
Summer 2009
INSIDE…
Local Matters
National Matters
International
Matters
Hot Websites
Cancer in the
News
Treatment
Matters
GP Matters
Consumer Matters
WACOG
All correspondence should
be directed to:
Executive Officer
46 Ventnor Avenue
West Perth WA 6005
Tel: +61 08 9212 4333
Email:
[email protected]
Website:
www.cancerwa.asn.au/
professionals/wacog/
Cancer Matters is published in
April, August and December as
a service to all supporters and
interest groups.
From the Editor
In this edition under local matters we highlight
issues surrounding multidisciplinary care (MDC) in the
management of cancer. Broadly MDC is defined as
an integrated team approach to health care in which
medical and allied health professionals consider all
relevant treatment options and develop collaboratively
an individual treatment plan for each patient. On Page
3 all the major MDC teams for the common malignancies
operating in WA public teaching hospitals are detailed
with locations and contact numbers. An update on the
activities of the WA Cancer and Palliative Care Network
from the Director Prof. Ian Hammond is also presented.
In our centre pages with permission from Andrology
Australia we present an article preapred by Professor RA
‘Frank’ Gardiner - a Queensland urologist, that appeared
in the latest issue of the newsletterThe Healthy Male
titled - Focus on: PSA testing: What everyman (and
health professional) needs to know. This is a very timely
piece that covers many of the contemporary controversies
related to the continued lack of conclusive evidence
regarding population screening for prostate cancer. Given
this situation - the emphasis for health consumer bodies
and health professionals (in particular GPs) should be on
assisting men to make informed decisions on whether to
have a PSA test/DRE (Prostate Specific Antigen/Digital
Rectal Examination. We feel this article helps clarify and
guide information discussions between men their doctors
on this important and controversial health issue.
HIGHLIGHTS
WA Multidisciplinary Cancer Teams
Page 3
Focus on PSA Testing
Centre Pages
New Cancer Screening Guidelines
Back Pages
Cost of a local call statewide
Weekdays 8am - 8pm
[email protected]
www.cancerwa.asn.au
Still on the issue of screening and early detection, Cancer
Cancer Council Australia and WACOG have released a
summary card on evidence for and against screening for
8 common malignancies. This card is a useful tool to guide
discussions between doctors and persons interested in
cancer screening. It also includes details on the WWW links
for further details regarding specific cancer screening
resources. The card has been reproduced in full on the
back pages of the newsletter so that it may be cut-out
for future reference.
In consumer matters the outgoing chair of Cancer Voices
WA, Clive Deverall presents an historical piece on his views
as a long standing cancer activist for almost 4 decades.
The WA and national cancer control community is richer
through the hard working endeavours in cancer advocacy
that Clive has undertaken and we send him best wishes in
his future pursuits. The newsletter also includes several
items in regular sections such national, international and
treatment matters and cancer in the news. In the website
section a review appears of the UK NHS Evidence Cancer, that is a comprehensive evidence-based resource
supporting health professionals to find the high-quality
cancer information they need to keep up-to-date.
Paul Katris – Editor
INFORMATION RESEARCH
SUPPORT
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1
CANCERmatters
LOCAL MATTERS
WA Cancer and Palliative Care Network
Director: Professor Ian Hammond
What is multidisciplinary care?
care is a collaborative approach to treatment
planning and ongoing care throughout the treatment
Multidisciplinary
Update on the National Bowel Cancer Screening pathway. Multidisciplinary care aims to ensure that members of
Program (NBCSP)
the treatment and care team can discuss all relevant aspects of a
he Department of Health and Ageing (DoHA) suspended cancer patient’s physical and psychosocial needs along with other
T
invitations for the NBCSP in May 2009, due to concerns over factors impacting upon the patient’s care.
faulty Faecal Occult Blood Test (FOBT) kits used since December
2008. DoHA has now announced that replacement kits will be
distributed from 2nd November 2009 to all those effected by the
faulty kits. The remedial action will be prioritised to firstly re-invite
those who previously participated and are at risk of having a false
negative FOBT result. The replacement kit has been assessed and
found fit for use by the Therapeutic Goods Administration (TGA), and
by the Commonwealth’s specially appointed, independent Expert
Advisory Group. Around 30,000 people in WA will be re-invited
prior to Christmas. The WA Bowel Cancer Screening Implementation
Team is liaising with key stakeholders to advise clinicians about the
influx of colonoscopies that will result from the remedial action. It
will be important for the community to be reminded to participate in
the NBCSP once it re-starts. FOBTs are proven to help detect bowel
cancer at an earlier, more treatable stage. Participants with a positive
FOBT result will need to be supported to reduce anxiety levels and
be made aware that there are waiting lists to access colonoscopy
services in WA. GPs can utilise the public waitlist, private specialists
or Ambulatory Surgery Initiative (ASI) to refer participants with a
positive FOBT for colonoscopic assessment. Participants with a
positive FOBT should ensure that all health professionals they deal
with are aware that they are an NBCSP participant. This will assist
clinicians in prioritising their care more effectively and increase
reporting of outcomes to the NBCSP Register. Any concerns or
queries from either clinicians or the community should be referred
to the National Helpline 1800 118 868.
Why is it important?
t is well documented and accepted that multidisciplinary care
represents best practice in terms of treatment planning and care
for cancer patients.
I
Multidisciplinary care encompasses:
•A focus on continuity of care,
•Development of pathways and protocols for treatment and care,
•Development of appropriate referral networks, including
appropriate referral pathways to meet psychosocial needs,
•Development of multidisciplinary team meeting audit mechanisms,
and
•Consumers/patients who consent to their case being discussed
by the multidisciplinary team and who understand the process,
know that they will be informed about the treatment and care
recommendations and will be involved in decision-making.
An effective multidisciplinary approach can result in:
•Improved treatment planning through consideration of a full
therapeutic range and thus improved outcomes,
•Improved team communication,
•Survival benefit,
•Increased recruitment into clinical trials,
•Detection of emotional needs of patients,
•Reduction in minor psychological morbidity of team members,
•Reduction in service duplication, improved coordination of services
and development of clear lines of responsibility, and
Cancer Models of Care
he WACPCN have continued to work towards producing Models •Improved sharing of incidental information and informal
of Care (MOC) for each tumour specific group. Models of Care information sharing prior to and after meetings.
frameworks are aimed at providing the optimal level of health care
for every cancer patient. The cancer Models of Care update is listed Multidisciplinary care is becoming an increasingly important
component of national and State/Territory cancer frameworks.
below:
The National Breast and Ovarian Cancer Centre is committed to
• Upper GI will be presented at the next SHEF meeting
improving the uptake of multidisciplinary cancer care, using lessons
• Head and Neck has been endorsed by SHEF
• Urology (prostate and penis) document has been consulted on learned from a number of key national projects. Comprehesive
by clinical and community stakeholders. This MOC will shortly information reagaring the role of multidisciplinary care in the
be presented to the Clinical Leads Forum and then to SHEF for mamangement of cancer along with many resources and useful
tool to facilitate teams undertaking such care models are available
endorsement
via the National Breast and Ovarian Cancer Centre’s website.
T
Cancer Database
he Department of Health has purchased a statewide Software
T
Database called MMEX. This database was developed by UWA
and is being adapted to meet the needs of the WACPCN for use
in multidisciplinary team meetings and in the development of the
statewide stage related clinical cancer database. The modified
version will enable health professionals to access information
on a wide range of health services, including pathology reports,
WA Cancer Registry, Multi-disciplinary Clinics. This will further
strengthen tumour specific data collection analysis. It is anticipated
the Department of Health demo version will be available late
February 2010. Professor Lin Fritschi is the lead clinician for the
project. The network is keen to adopt the database which will also
incorporate tumour site specific data sets. This will be essential in
the improvements to cancer care in WA.
Cancer Learning
he Cancer Learning online hub is designed to facilitate access
T
to learning materials for health professionals working in cancer
care. It includes resources developed by two major projects funded
Resources
ational Breast and Ovarian Cancer Centre has developed
a number of guides to assist health services and health
professionals implement a multidisciplinary approach to cancer
care based on outcomes from a number of national projects and
forums.
The guides are all available here:
http://www.nbocc.org.au/health-professionals/clinical-bestpractice/mdc-guides
• Multidisciplinary care for advanced disease: a guide for cancer
health professionals
• Multidisciplinary meetings for cancer care: a guide for health
service providers
• Medico-legal implications of multidisciplinary treatment planning
meetings
• Information about the new MBS items for multidisciplinary cancer
care
N
through the Australian government’s Strengthening Cancer Care
initiative: Professional Development Packages Project and the
national Cancer Nursing Education project (EdCaN). This information
and the link for Cancer Learning has recently been included in the Further information
WACPCN website.
Achieving best practice cancer care: A guide for implementing
multidisciplinary care. Department of Health Victoria:
Website
ll endorsed Models of Care, Cancer Learning link and other http://www.health.vic.gov.au/cancer/docs/mdcare/
multidisciplinarypolicy0702.pdf
activities of the WACPCN are available on the website:
http://www.healthnetworks.health.wa.gov.au/cancer/home/
SEE DETAILS REGARDING WA PUBLIC HOSPITAL CANCER
index.cfm
MULTIDISCIPLINARY TEAMS ON THE OPPOSITE PAGE
A
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2
Orthopaedic Outpatients
9346 1189
9340 1383 (written/faxed
referrals preferred)
9346 3632
6477 5008
9431 3333 and ask for F5
9382 9445
9346 3110 or 4861
9224 2185
9431 3333
9346 3632
6477 5008
9431 3333 and ask for F5
9346 1756
9224 2903
9431 2762
9346 3089
9224 3039
9431 2144
9346 7610 or 3821
9224 2405
9431 2886
9346 4590
6477 5008
Telephone
Medical Oncology
Medical Oncology
Medical Oncology
Fremantle Hospital
Royal Perth Hospital
Sir Charles Gairdner Hospital
9346 1873
9224 3126
9431 2580
9346 3147
9340 1016
9346 3712
9224 2860
9431 2338
9382 9446
9346 4862
9224 2168
9431 2338
9346 3712
9224 2860
9431 2338
9346 1555
9224 2385
9431 2759
9346 4899
9224 1779
–
9346 7620
9224 3449
9431 2881
9346 4897
9224 2860
Facsimile
Ground Floor, B Block, SCGH, Hospital Avenue, Nedlands. WA 6009
Outpatient Appointments, RPH, Box X2213 GPO, Perth. WA 6848
Referrals, Fremantle Hospital and Health Service, PO Box 480, Fremantle WA 6959
Ground Gloor, E Block, Outpatient Building, SCGH, Hospital Avenue, Nedlands. WA 6009
Gynaecological Oncology Department, West Wing Clinic, A Block, KEMH,
374 Bagot Rd, Subiaco WA 6008
7th Floor, G Block, SCGH, Hospital Avenue, Nedlands WA 6009
Outpatient Appointments, RPH, Box X2213 GPO, Perth WA 6848
Fremantle Hospital and Health Service, PO Box 480, Fremantle WA 6959
[email protected]
7th Floor, G Block, SCGH, Hospital Avenue, Nedlands WA 6009
Outpatient Appointments, RPH, Box X2213 GPO, Perth WA 6848
Fremantle Hospital and Health Service, PO Box 480, Fremantle WA 6959
7th Floor, G Block, SCGH, Hospital Avenue, Nedlands WA 6009
Outpatient Appointments, RPH, Box X2213 GPO, Perth WA 6848
Fremantle Hospital and Health Service, PO Box 480, Fremantle WA 6959
Ground Floor, B Block, SCGH, Hospital Avenue, Nedlands WA 6009
Outpatient Appointments, RPH, Box X2213 GPO, Perth WA 6848
Fremantle Hospital and Health Service, PO Box 480, Fremantle WA 6959
Ground Floor, E Block, Outpatient Building, SCGH, Hospital Avenue, Nedlands WA 6009
Outpatient Appointments, RPH, Box X2213 GPO, Perth WA 6848
Fremantle Hospital and Health Service, PO Box 480, Fremantle WA 6959
Ground Floor, E Block, SCGH, Hospital Avenue, Nedlands WA 6009
Outpatient Appointments, RPH, Box X2213 GPO, Perth WA 6848
Fremantle Hospital and Health Service, PO Box 480, Fremantle WA 6959
1st Floor, G Block, SCGH, Hospital Avenue, Nedlands WA 6009
Outpatient Appointments, RPH, Box X2213 GPO, Perth WA 6848
Postal/email address for non urgent referrals
Visit www.healthnetworks.health.wa.gov.au/cancer
for more information about state-wide cancer services.
9346 1222
9224 2334
9431 2411
Where a diagnosis is uncertain, contact Medical Oncology at the following hospitals
Sir Charles Gairdner Hospital
Sarcoma
Gynaecological Oncology Department
Colorectal Surgeon, General Surgery
Sir Charles Gairdner Hospital
King Edward Memorial
Hospital for Women
Colorectal Surgeon, General Surgery
Royal Perth Hospital
Gynaecological
Colorectal Surgeon, General Surgery
Fremantle Hospital
Colorectal
Melanoma Clinic
Department of Urology
Sir Charles Gairdner Hospital
St John of God, Subiaco
Department of Urology
Royal Perth Hospital
General Surgery
Sir Charles Gairdner Hospital
Urology Outpatient Clinic
General Surgery
Royal Perth Hospital
Fremantle Hospital
General Surgery
Respiratory Medicine
Sir Charles Gairdner Hospital
Fremantle Hospital
Respiratory Medicine
Royal Perth Hospital
ENT Department
Sir Charles Gairdner Hospital
Respiratory Medicine
ENT Department
Royal Perth Hospital
Fremantle Hospital
ENT Department
Haematology Department
Sir Charles Gairdner Hospital
Fremantle Hospital
Haematology Department
Royal Perth Hospital
Melanoma
Urological
Upper GI
Lung
Head & Neck
Haematology Department
Fremantle Hospital
Breast Assessment Centre
Sir Charles Gairdner Hospital
Haematological
General Surgery
Royal Perth Hospital
Breast
Contact/Department
Hospital with MDT
Tumour type
Contact details for referral to service
Hospitals with Tumour site-specific Multidisciplinary Assessment Clinics
CANCERmatters
LOCAL MATTERS
cont/d....
Study probes job link to cancer
WA researchers are to launch a groundbreaking study of thousands of women to determine whether
their job or the type of hours they work increase their risk of breast cancer. about 3,000 women
selected randomly from the State electoral roll or obtained from the WA Cancer Registry, will be sent
letters asking them to take part in the study, which will look for possible triggers of cancer, including
the workplace, exposure to toxins and shift work. The study follows on from previous studies in mice
which showed a link between shift work and a higher risk of breast cancer, and its findings could have
big implications for workers such as nurses, hospitality industry staff and airport workers.
The WA Institute for Medical Research will use software technology to track the lifestyle and genetic
profiles of women aged between 18 and 80 to see what factors might cause or protect against breast
cancer.
Lead investigator Professor Lin Fritschi said the study would look at women who had been diagnosed
with breast cancer and those who did not have the disease to look for common patterns like shift work
and toxins in the environment which were risk factors for the cancer. “We will be assessing factors like
pesticides in or near the workplace, including diesel, petrol exhausts and heavy solvents, as well as
pregnancy and fertility, and physical activity,” she said.
NATIONAL MATTERS
Cancer tests a waste of case: experts
A
ustralian women are being warned against paying hundreds
of dollars to be tested for ovarian cancer, with experts
arguing current technology is not accurate enough and could give
misleading results.
The National Breast and Ovarian Cancer Centre said yesterday
there was no evidence that tests such as the blood test CA 125,
ultrasounds or pelvic examinations reduced the number of deaths
from ovarian cancer. Testing women with no symptoms ran the
risk of falsely reassuring women that all was well, or causing
unnecessary and highly invasive procedures on the basis of a
false positive result. The new advice, published in the Australian
and New Zealand Journal of Obstetrics and Gynaecology, is in
response to growing interest in new blood tests which look for
biomarkers or proteins that can point to the presence of ovarian
cancer cells. The centre’s chief executive officer Helen Zorbas
said although it was understandable that women were seeking a
screening test for the disease, there was no evidence to support
the use of any test or combination of tests.
“We know that early detection of ovarian cancer is critical to
reducing the number of lives lost to the disease, however there
is currently no evidence (that tests) will help to reduce deaths
from ovarian cancer in women who do not have any symptoms of
the disease,” Dr Zorbas said. Chairman of the Australian Society
of Gynaecologic Oncologists Jonathon Carter said testing women
without symptoms could not only lead to some being falsely
reassured, it could also lead to unnecessary procedures in other
women. but he said women who had persistent symptoms such
as abdominal bloating, loss of appetite or unexplained weight
gain or loss should see their doctor.
Cancer Council WA Director of education and research Terry
Slevin said the new advice was based on available evidence
which suggested no single test or combination of tests could
find ovarian cancer early enough for it to reduce the chances of
dying from the disease.
Clinical minimum data set for breast cancer
t is recognised among policy and decision-makers that quality
IData
data is essential to cancer control. While the National Health
Dictionary recommends a core set of generic data items for
clinical cancer registration, this list does not include items for
specific tumour streams.
To address this, National Breast and Ovarian Cancer Centre
(NBOCC) has developed breast cancer specific data items for
clinical cancer registration and data dictionary definitions to
facilitate comparative analysis and, where appropriate, data
pooling. The data dictionary definitions were developed through
an NBOCC multidisciplinary working group, in consultation with
key stakeholders, and are drawn from data dictionary definitions
in key datasets already in use across Australia. NBOCC is
committed to working in collaboration with key stakeholders
to promote the adoption of the clinical minimum dataset for
breast cancer to ensure a nationally consistent approach to the
collection and reporting of data.
The dataset and definitions are available to download from
www.nbocc.org.au/resources. For more information, please
contact Trenna Rowe at [email protected] or
02 9357 9437.
Breast cancer deaths on wane
he number of Australian women diagnosed with breast
T
cancer annually has more than doubled over the past 25
years, but fewer are dying from the disease.
The most comprehensive review of breast cancer to date,
released by the Australian Institute of Health and Welfare and
the National Breast and Ovarian Cancer Centre, also found that
Indigenous women are significantly less likely to be diagnosed
with breast cancer.
However, poor access to healthcare and a reluctance to follow
up on treatment meant those Indigenous women diagnosed
with the disease were less likely to survive.
The report, titled Breast Cancer in Australia - An Overview 2009,
showed that 12,614 Australian women were diagnosed with
breast cancer in 2006, up from 5,289 in 1982. The number of
breast cancer-related deaths fell by 27 per cent between 1994
and 2006, with only 22 fatalities per 100,000 women.
The report found that while much of the increase in the number
of women diagnosed with breast cancer was due to a growing
and ageing population, women were now more likely to have
breast screens, which was boosting detection levels.
Celebrities such as Kylie Minogue and Belinda Emmett had
increased awareness of the importance of getting mammograms,
said Helen Zorbas, chief executive of the NBOCC. “Many breast
cancers are found early due to screening, and these women
definitely raised the profile of how important this is,” she said.
According to the report, between 2002 and 2006, only 65 per
cent of Indigenous women survived breast cancer, compared
with 82 per cent of non-Indigenous cases. Ms Zorbas said this
was due in part to fewer Indigenous women initially requesting
breast screens, and once diagnosed, following up on treatment.
“There are a number of factors that contribute to this but we
know that Indigenous women are much less likely to participate
in mammogram screening,” she said. “There may also be genetic
differences that may predispose them to the mortality rates
we are seeing.” According to the report, the number of women
diagnosed with breast cancer is projected to continue to increase,
with an estimated 15,409 cases in 2015.
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CANCERmatters
INTERNATIONAL MATTERS
Breast cancer taking a toll on poorer countries
B
reast cancer is becoming an increasingly global epidemic,
plaguing more people in developing countries where mortality
rates are higher and many lack access to care, US researchers
warned.
“We used to think breast cancer was a problem of only wealthy
women, but now we know breast cancer shows no favourites, it
strikes rich and poor women alike,” says Felicia Knaul, PhD, who
heads the Harvard Global Equity Initiative. “The only difference
is that by the time the disease is diagnosed in poor women, it is
often too late for effective treatment.” About 1.35 million cases
of breast cancer will be diagnosed worldwide in 2009, accounting
for 10.5 per cent of new cancers, according to the study by the
Harvard School of Public Health. Breast cancer cases are expected
to surge by 26 per cent by 2020 with 1.7 million new cases,
most of which will be in low- and middle-income developing
countries, the researchers said. This year more than 55 per cent
of the 450,000 reported breast-cancer deaths worldwide are in
countries without the resources to deliver early diagnosis and
treatment. That is why the likelihood of dying from breast cancer
- which is highly treatable if caught early on - hits a high of 56
per cent in the poorest countries, 39 per cent in middle income
countries and just 24 per cent in the wealthiest countries.
“To attack the breast cancer global problem, there is not a onesize-fits-all solution,” said Dr Lawrence Shulman, head of the
Dana Farber Cancer Institute.
Key issues include the lack of adequate infrastructures for patient
care; getting women to come in for screening; and overcoming the
social stigma associated with breast cancer, researchers added.
Cancer Patients Want Honesty From Doctors
By: Charlene Laino November 6, 2009
f you had cancer, would you want to be told your odds of dying?
Ibreast,
Absolutely, suggests a survey of more than 500 people with
lung, or prostate cancer. Ninety-five percent said they
wanted their doctor to be honest about their chances of a cure
and how long they can expect to live, says Ajay Bhatnagar, MD,
a radiation oncologist at the University of Pittsburgh Cancer
Institute in Pittsburgh. Men with prostate cancer were more
likely to want their doctors to be honest about their odds of
survival than people with lung cancer: 97% vs. 91%, he says.
While respondents were not asked why, “we think that has to
do with the fact that is pretty well known that the prognosis for
lung cancer is quite dismal,” Bhatnagar tells WebMD. Men with
prostate cancer, on the other hand, “have an excellent prognosis
and we think they like to hear that reaffirmed by their physician,”
he says. The findings were presented at the annual meeting of
the American Society for Radiation Oncology (ASTRO).
Patients Want Informal Doctors
The survey findings also suggest that many patients want their
doctors to shed the formality, Bhatnagar says. Nearly threefourths of those surveyed said they prefer to be called by their first
name. And 79% said they didn’t care if their doctor dons a white
coat; 70% don’t care if their doctor dresses professionally, in suit
and tie or a dress. Only 17% said they would be put off by a hug
after a two-month course of radiation treatment. And one-third
of women with cancer said they’d like to have their hands held
by their oncologists during important office visits, as would 12%
of men.“The findings are reminiscent of the trusting relationship
between patients and doctors of 50 years ago. Doctors have
changed, but patients haven’t,” says Harvard Medical School’s
Anthony Zietman, MD, incoming president of ASTRO. “Patients
want doctors to stop hiding behind the technology.”
Explaining Treatment in Everyday Language
Bhatnagar says 84% of respondents said they want their doctor
to explain their treatment plan in detail; 95% said they want
their doctor to use everyday terms when they do so.
“Physicians need to be more aware of this preference and take
the time and effort to explain details in everyday language,” he
says. And if they don’t? Then patients should take matters into
their own hands, Zietman says. “Tell your doctor to slow down,
talk things through. If you don’t understand something, stop
them.”
When it comes to religion, 40% of respondents said they’d be
comfortable talking about their own beliefs. But 30% said they
would be uncomfortable if their doctors talked about their
beliefs.
“Patients don’t want doctors imposing their own view of religion,
but might like doctors to foster [the patient’s] own beliefs,”
Bhatnagar says. The study involved 508 patients undergoing
radiation for breast, prostate, or lung cancer between June
2006 and March 2008. They filled out a written survey asking
whether they agreed or disagreed with, or felt neutral toward, 10
statements focusing on the patient-doctor relationship.
SOURCES:
•51st Annual Meeting of the American Society for Radiation
Oncology, Chicago, Nov. 1-5, 2009.
•Ajay Bhatnagar, MD, radiation oncologist, University of Pittsburgh
Cancer Institute, Pittsburgh.
•Anthony Zietman, MD, incoming president, ASTRO; Harvard
Medical School.
HOT WEBSITES
http://www.library.nhs.uk/Cancer/
NHS Evidence - Cancer is a comprehensive evidence-based resource supporting health
professionals to find the high-quality cancer information they need to keep up-to-date. NHS
Evidence - cancer undertakes systematic searches to identify all systematic reviews relating
to cancer - to provide the most reliable answers to healthcare questions. They have created
'evidence collections' for each cancer type and for each clinical activity which, via the contents
pages, links to up-to-date collections of systematic reviews.
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5
Focus on: PSA testing: What everyman (aan
Author: Professor RA 'Frank' Gardiner
Although there is limited evidence that PSA testing reduces the
risk of death from prostate cancer, there has been a noticeable
change recently with more men now asking for information
about being tested.
Prostate cancer ‘Testing Journey’
STAGE ONE:
What is a PSA test and when is it used?
Prostate Specific Antigen (PSA) is a protein made mainly in the
prostate and is normally found in low levels in a man’s blood
stream. A PSA test measures the level of PSA in the blood and
may help to diagnose prostate disease. A high PSA in the blood
almost always means that something is wrong with the prostate,
but not necessarily prostate cancer.
A high PSA may be found in men who have prostatitis
(infection or inflammation of the prostate), benign prostatic
hyperplasia (BPH known as prostate enlargement), or least
commonly, prostate cancer.
Why is the decision to have a PSA test a complex one?
A single PSA test is not a reliable sign of prostate cancer on its
own. Once a decision is made to be tested for prostate cancer,
a man starts on a ‘testing journey’ made up of three stages that
can continue for the rest of his life. If the additional stages
are not discussed with a man prior to his decision to have
the first PSA test and he receives an abnormal PSA result, the
additional stages can be highly unexpected and may cause
psychological distress.
The decision to have a PSA test should be made with the
understanding of all possible outcomes; including the physical
and psychological side-effects that can come with further testing,
prostate cancer diagnosis and its various treatment options, which
may include erectile dysfunction and continence problems.
For men diagnosed with prostate cancer, there are three treatment
possibilities: i) curative intent (radical prostatectomy or radiation
therapy); ii) commencement of androgen deprivation therapy
(ADT) following monitoring (watchful waiting) and iii) active
surveillance (which includes further biopsies). Monitoring may
be measuring PSA (+/- DRE) with a view to commencing ADT at
some later date or by active surveillance (involving PSA, DRE and
further biopsies). An increasing number of men diagnosed with
prostate cancer are proceeding to active surveillance for what is
considered to be cancer with a low-risk of progression; with the
option of radical prostatectomy or radiation therapy reserved
for those men whose cancers subsequently show evidence of
progressing as revealed by intense monitoring.
A cancer diagnosis is complicated by the fact that in about 1 in 4
men prostate cancer may act in an aggressive fashion (e.g. spread
to lymph nodes and to bone which may have already occurred at
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and health professionals in a form that they can easily
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decision and diagnosis may have.
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presentation but may not be demonstrable with imaging tests),
while in another 1 in 4 men the cancer remains indolent (e.g.
remaining localised to the prostate). At this stage there is no
useful marker to identify which cancers will behave in an indolent
or an aggressive fashion.
One in eight men diagnosed with prostate cancer will die of the
disease with this number varying depending on age and Gleason
score of disease at diagnosis, with younger men diagnosed with
more advanced cancer more likely to die from the disease (as
there are fewer competing causes of death or co-morbidities, such
as cardiovascular disease which is increasingly common as men
become older.)
What if I’m a man thinking about prostate cancer testing?
Men should be aware that there is debate about the potential
gains and risks from PSA testing and prostate cancer treatment
options. If you are considering having your first PSA test/DRE,
you should discuss the following with your doctor and use the
resources listed to help guide the discussion:
Kindly provided with permission from Andrology Australia
6
(aand health professional) needs to know
> PSA levels rise as a normal part of ageing as the prostate tends
to grow larger so the ‘normal’ levels (or reference range) of PSA
must be adjusted for a man’s age. Even when the PSA level is
within the normal range for that age group, a PSA velocity (the
time it takes for PSA levels to increase, such as a doubling over
12 months) trigger further investigation by your doctor
> Increases in single PSA levels taken at age 40 years (cut-off
0.6 ng/ml) and 50 years (cut-off 1.5 ng/ml) may suggest an
increased risk of prostate cancer over the next 10-20 years
> The combination of a DRE with a PSA improves detection rates.
However a DRE only allows a doctor to feel that part of the
prostate immediately in front of the rectum (back passage) but
not the other areas of the prostate that could also be affected
by cancer
> An abnormal PSA/DRE needs further assessment by a urologist
(specialist) to confirm if this is due to a growing cancer or a
non-cancerous problem such as prostatitis (inflammation due to
infection) or benign prostatic hyperplasia (BPH)
> The limitations of PSA testing should be discussed with your
doctor; including the inability of the PSA test to confirm
prostate cancer or to detect how advanced the cancer is and
how quickly it is progressing
> A normal PSA test (combined with a negative DRE) reduces the
chance that prostate cancer is present but does not exclude it
completely
> There is no level of PSA that identifies whether a man does or
does not have prostate cancer
ES
What if I have a family history of prostate cancer?
Men with a strong family history of prostate cancer (whether a
grandfather, father, brother, uncle or cousin with the disease) are
at a greater risk of cancer and should think about being tested
from 40 years of age. On average, hereditary prostate cancer may
develop six years earlier than non-hereditary prostate cancer.
A history of breast cancer in female family members can also be
linked with a higher risk of prostate cancer in men. It is important
to discuss any family history of disease with your doctor.
What if I’m a health professional talking to my
patients about prostate cancer testing?
Being tested for prostate cancer should be a shared decisionmaking discussion between a man and his doctor, and should only
happen if a man is properly informed of the potential gains and
risks of testing and then agrees to proceed with testing. It is not
appropriate to order a PSA test without a patient’s knowledge
or as part of a suite of blood tests unless the patient has been
adequately informed.
It is essential that any health professional ordering and discussing
PSA testing is up-to-date with the scientific evidence and ensures
that balanced evidence-based information and resources are
provided to the patient before a decision is made.
A man seeking PSA testing should be given access to written or
web-based, relevant material which is evidence-based (when this
is available), is easy to read and understand, and is endorsed by
reputable professional bodies. Any information provided should be
given in a way that respects the man’s education level, personal
circumstances, language skills and culture, and is sensitive to the
man’s values and personal preferences. It should not be assumed
that patients requesting PSA testing are adequately informed.
Health practitioners should recognise that an abnormal PSA
test followed by a biopsy, that shows even low-risk cancer, may
have the potential to cause anxiety and distress for some men.
However, providing information and support is likely to help men
to maintain a good quality of life without psychosocial stress,
even if there is a cancer diagnosis. Such support is particularly
important through all stages of testing and treatment.
Referral to a urologist is essential for assessment of an abnormal
PSA result including a low free/total PSA ratio, or a rapidly rising
PSA. Early referral to a urologist is recommended for consideration
of transrectal ultrasound (TRUS)-guided biopsy. The urologist must
provide full information about the possible TRUS findings, risks
and subsequent management options to the man and his doctor.
What health information and resources are available
on PSA testing?
Current resources which provide information based on the current
evidence available include:
> Andrology Australia website (www.andrologyaustralia.org)
> Fingertip Urology (www.bjui.org/FingertipUrology.aspx)
Topic: ‘Whether to test for Prostate Cancer’
(including PSA Decision Card)
Topic ‘Pertinent Points in Prostate Cancer’ Appendix 2:
Age-related ranges for Caucasian and Asian men
> Lions Australian Prostate Cancer website
(www.prostatehealth.org.au)
> PSA Decision Card: ‘The Early Detection of Prostate Cancer in
General Practice: Supporting Patient Choice’. Available from:
www.andrologyaustralia.org/docs/PSAdecisioncard20041007.pdf
Where do we go from here?
Newer and more specific prostate cancer markers are needed
before an effective population-wide prostate cancer screening
program can be trialled, recommended or implemented. The key
challenge for any prostate cancer population-screening program
is to identify men with aggressive cancer, and to intervene early
and effectively.
There is no current recommendation for population-wide
screening for prostate cancer in Australia by government or
professional societies, including the Urological Society of Australia
and New Zealand and the Cancer Councils of Australia. This lack
of recommendation is due to the lack of evidence.
Until such evidence is available, targeted testing of informed
individuals is considered appropriate practice. PSA testing
combined with DRE is currently considered to be the most suitable
method of identifying men at risk of having prostate cancer.
A full list of references for this article is available by emailing
[email protected]
Kindly provided with permission from Andrology Australia
7
CANCERmatters
CANCER IN THE NEWS
Anti-smoking WA ‘feared by tobacco companies’
Curtin University investigation has revealed that WA has been
closely monitored by the world’s biggest tobacco companies
for more than 50 years, with internal memos warning of the
State’s “alarming” anti-tobacco stance.
Under a document-searching research program, the university
has found that US tobacco executives have been keeping a keen
eye on changing WA governments and anti-tobacco lobbyists
since the 1950s, worried that their efforts could “spread” to other
States.
Internal memos between senior executives from companies
including Philip Morris in the 1990s warned of WA “taking the
lead” in considering measures such as bans on tobacco advertising
and raising taxes on cigarettes.
The Curtin documents show Philip Morris funded Swedish scientist
Ragnar Rylander visited the University of WA on the premise of
research, but he later supplied detailed reports about WA’s antitobacco activities to company executives in New York.
Australian Medical Association WA president Gary Geelhoed, who
will launch the report, said the documents showed the lengths
that tobacco companies went to. “In many ways it shows WA has
been a leader in tobacco control for many years, and although we
still haven’t gone as far as we would want and can’t be complacent,
we have come a long way against a lot of industry resistance,” he
said.
The first attempted evaluation of the national bowel cancer
screening program shows that 29% of patients aged 55 and 65
who were diagnosed with bowel cancer within the first two years
of the scheme’s launch in 2006, were picked up as a result of their
participation.
In addition to dramatically boosting detection rates, the program
has resulted in many more cancers being diagnosed early, when
they are much easier to treat effectively. Of the 40 cancers
detected through the screening program, 16-40% were still in the
first stage of the disease’s progression and only one patient had
stage four, indicating a cancer that had spread to other parts of
the body.
That is the reverse of the pattern normally seen in patients whose
cancers are picked up by other means. In the 1,588 patients
whose bowel cancer came to light through the investigation of
symptoms, only 14% had stage one disease, while 31% had stage
two, 24% stage three and 15% stage four. Overall, the impact of
the screening program on total numbers diagnosed with bowel
cancer remained small, because the scope of the program was
tightly constrained when it first launched including only people
turning 55 and 65 each year.
But Sumitra Ananda, a medical fellow at the Royal Melbourne
Hospital and lead author of the research, said the program was
still too limited and experts remained hopeful the scheme would
gradually expand to include all Australians aged more than 50,
recalling them for follow up screening every two years.
Lack of checking puts women at cancer risk
New leukaemia treatment doubles remissions
A
new treatment for the most common form of adult leukaemia,
A
that is about to be made available to Australians, has been
found to nearly double the number of patients who go into
A
ustralian women are being urged to have regular checks for
breast cancer after two studies found many may be missing
out on early lifesaving treatment because they are not doing self
examinations or having routine breast X-rays.
An Australian Institute of Health and Welfare report being
released today shows the number of women aged 50 to 69 having
mammograms through the Commonwealth-funded BreastScreen
program has remained at 56 per cent in the past decade, falling
short of the 70 per cent target.
It also shows a significant fall in the proportion of women aged
40-49 being screened. While women in this age group are not
recruited into the program, they can have a free mammogram if
they request it.
Dr Alison Budd, from the Institute’s Cancer and Screening Unit, said
the latest figures showed screening was picking up an increasing
number of cases of breast cancer and more than 60 per cent of
invasive cancers detected were only small. Conversely, deaths
from breast cancer in women aged 50-69 had fallen steadily over
the past 15 years.
In 1991, 230 women per 100,000 in the 50-69 age group
developed breast cancer, and 67 in 100,000 died.
But by 2005, despite 279 new cases for every 100,000 women,
the mortality rate had dropped to 47.5 - the lowest level since the
program began.
Separate survey results released yesterday by the McGrath
Foundation, named after Jane McGrath who died of breast cancer
last year, raised concerns that while most women believed they
were “breast aware”, many were not checking their breasts for
lumps or going to their doctor for an examination.
Foundation executive director Tracy Bevan said the national
survey of more than 1,000 women aged 18 and over found
that only one-third of women carried out regular breast selfexaminations.
While nine out of 10 women reported having dental checks and
eight out of 10 had Pap smears, 32 per cent of women said they
had never had a breast examination by a doctor.
Free screening for bowel cancer boosts detection and
saves lives
early one-third of people diagnosed with bowel cancer aged
N
55 and 65 found out they had the disease only because they
took up the offer of a free screening test - a decision likely, in at
least some cases, to save their lives.
remission.
Melbourne’s Peter Mac Cancer Centre played a key role in
the research that showed the drug MabThera, a 10-year-old
treatment for non-Hodgkin’s lymphoma, also had a powerful
effect countering the blood cancer, adult leukaemia.
When used in combination with chemotherapy, almost twice as
many patients with chronic lymphocytic leukaemia (CLL) go into
remission, and they lived longer without the disease compared
with chemotherapy alone, said Associate Professor John
Seymour.
“This is the largest single advance in the treatment of this disease
in the last 30 years,” Professor Seymour said. “In most medicines
we are used to small steps, this is an improvement of substantial
magnitude.”
The drug was previously only available to treat lymphoma: it has
just received approval from the Therapeutic Goods Administration
(TGA) for prescription for new cases of CLL.
RACGP rejects new advice on PSA testing at 40
xperts are clashing over the revised PSA testing
E
recommendations released by the Urological Society of
Australia and New Zealand which state all men “interested in
their prostate health” should be offered PSA testing and rectal
examination from age 40.
The debate follows results from two international trials that the
Society says suggests a baseline PSA measure at 40 should guide
future management.
However, the RACGP and primary care academics are rejecting the
advice, arguing the new evidence is not strong enough to change
policy.
Professor Simon Chapman, professor of public health at the
University of Sydney, described the policy as “reckless”. “There
will be a large number of Australian men who will be investigated
for prostate cancer, and then a proportion of them will undergo
surgery, and an unacceptably high number of those will have
serious side-effects as a result,” he said.
Professor Mark Harris, chair of the editorial group for the RACGP’s
Guidelines for Preventative Activities in General Practice, said
“The RACGP believes there is insufficient research evidence at
present to justify recommending screening at any particular age.”
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8
CANCERmatters
TREATMENT MATTERS
Shorter breast cancer radiation safe
omen with early breast cancer can now benefit from less gruelling treatment, after researchers found giving high-dose radiation
W
therapy in half the time could be just as effective as longer courses with more side effects.
Study results presented at the American Society for Radiation Oncology in Chicago in November showed that giving women with early
stage breast cancer a shorter but more intensive course of radiation after they had the lump removed, was safe.
Doctors said instead of a seven-week course, women could be offered treatment shortened to three or four weeks using a high-dose,
targeted form of radiation known as intensity-modulated radiation therapy. This meant skin and organs such as the lungs and heart
were more protected, reducing potential side effects.
High intensity exercise reduces fatigue
By Louise Wallace taken from Omnus Oncology 30/10/09
Words not enough for informed consent
By Nicola Garrett
- Taken from Omnus Oncology Update Oct 2 2009
igh intensity exercise is safe for cancer patients undergoing
hile doctors often describe the risk of treatment side-effects
H
chemotherapy and is associated with a range of emotional,
W
to patients in words, they should qualify them with numerical
functional and physiological benefits, a Danish study concludes.
values to ensure patients understand risk, Australian oncologists
Researchers allocated 269 cancer patients to a supervised
exercise regime of high and low intensity training for nine hours
a week, or conventional care.
At 6 weeks, those in the exercise group had less fatigue and
reported improved vitality, aerobic capacity and physical and
functional activity.
They were also stronger and had better general and emotional
wellbeing. By the end of the study period, patients in the
exercise group were also able to partake in demanding activities
without health related constraints and also showed significant
improvement in terms of mental health.
In line with other recent studies, no participants reported
significant improvements to their quality of life, which shows high
intensity exercise is “not able to overcome the overall complexity
of patients’ negatively affected situation”, the study authors
wrote in the BMJ. They noted that a limitation of the study was
the 71% adherence rate and a 53% recruitment rate.
Furthermore, they said the good performance status (WHO 0-1)
of the study group and the exclusion of people with brain or bone
metastases meant the intervention may need to be modified in
patients with a performance status of 2 or greater.
“Our results show small to medium effect sizes across a broad
spectrum of physical and emotional wellbeing scales, we found a
reduction in fatigue which we consider to be of importance to the
patients’ daily lives,” they concluded.
BMJ 2009;339:b3410
say. The study of 262 women with early breast cancer found
that most women underestimated risk when asked to assign
numerical values to the phrases ‘sometimes’, ‘uncommon’, ‘very
uncommon’, ‘rare’, ‘very rare’.
Associate Professor Peter Graham and colleagues from the cancer
Centre at St George Hospital, Kogarah, NSW, said the range of
interpretations and the consistent assignment of extremely low
frequencies of risk generally ‘render descriptive words without
numerical quantification inadequate for informed consent’.
“In most instances for most of the phrases tested, risk description
for a serious complication appears to be inadequate if the doctor
is trying to convey the quantum of risk, and not simply that a
particular complication is possible,” they wrote in the Asia Pacific
Journal of Clinical Oncology. The doctors also found that a
patient’s preference for potential treatment complications to be
described descriptively or numerically depended on their level of
education.
Numerical expressions were preferred by 75% of women with
a university or post-graduate qualification, 40% of women with
secondary education and 63% of women with college or other
non-university education.
A more advanced cancer stage and older age also increased the
preference for descriptive words.
“If decision boards or similar information summaries are provided
to patients to facilitate therapy decisions with possible side
effects numerical values should be attached to any risks
grouped by frequency and labelled with words such as common,
uncommon, or rare,” they concluded.
Asia-Pac J Clin Oncol 2009; 5:193-199.
GP MATTERS
009 was a successful year for Cancer Council WA’s GP education program. We held 10 GP education sessions, which were attended
2
by over 350 GPs and 70 other health professionals. We published two new resources for GPs – two A4 cards; on cancer prevention
and diagnostic imaging.
Next year is also shaping up to be busy, with potential events on new breast imaging technologies, follow up of cancer in general
practice, cancer treatment, alcohol, diagnostic imaging, skin cancer and of course the 6th Annual Women’s Health Day. For information
on upcoming GP education events in 2010, or if you would like to suggest a topic for future GP education session events, please
contact the GP education coordinator on (08) 9388 4300.
Upcoming GP Education Events
On now!
On now!
Online: Cancer screening module
Online: Bowel cancer screening
www.gplearning.com.au
www.gplearning.com.au
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9
Clive Deverall - Consumer Representative
Some strange events - a consumer perspective
A
fter thirty two years working in the cancer sector, including the
last nine as a consumer representative in a variety of settings,
I am moving out and onto other things. But – a brief glimpse down
the corridor of time….
No one can forget or bury the Tronado which was firmly on the
agenda in the mid 1970s. Despite two reviews by the NH&MRC, a
clinical trial funded by the WA Health Dept and supervised by the
Cancer Council all of which found no therapeutic benefit (curatively
or palliatively), the treatment (in a modified form) still continues
to be provided at the Radiowave Therapy Clinic in Claremont.
You have to ask why? Was it the relentless national promotion 4
years ago by Ray Martin on Channel 9 (without doubt one of the
most sustained, cringe-making episodes of so-called television
journalism this country has ever seen)?. Or is it the enthusiastic
and powerful word-of-mouth endorsements over so many years
from patients who claimed they had been cured or had enjoyed
extended survival or relatives and friends of deceased patients
who, long afterwards, claimed the same effect? But how many
have there been – men, women and children – who have made
the ‘pilgrimage to Perth’ only to die far away from home or just
make it back from whence they came to die shortly thereafter and
somewhat poorer? The late Justice Lionel Murphy springs to mind
having been persuaded to come to Perth, to no avail, by former
premier John Tonkin. The answer has to be – hundreds, if not
thousands; especially after ‘Dr’ Ray Martin’s promotional efforts
on Channel 9. Did Ray Martin or his team want to hear about very
distressed patients, including a child, who had something negative
to say? No: that never fitted A Current Affair’s agenda.
In the same era of the 1970s Perth was visited by the late Dr
Ernesto Contreras who had developed and promoted Laetrile –
the so-called ‘Vitamin B 17’, sometimes labeled as Amygdaline.
A pathologist from the international capital of unproven cancer
‘cures’ – Tijuana in Mexico, Dr Contreras spent a day in Perth
extolling the merits of Laetrile on local TV & radio but refused to
debate his claims in public. Laetrile is still one of the biggest selling
‘products’ purchased by cancer patients around the world. And then
there was the so-called Doctor Milan Brych who was championed
by Sir Joh Bjelke Petersen. He treated hundreds of patients who
had the resources to make their way to the Cook Islands. After
a couple of years taxi drivers had renamed a local cemetery in
Raratonga the ‘Brychyard’ – a final resting place for those patients
who never returned.At the time commercial television stations in
Perth competed for footage of ‘cured’ patients returning to Perth
from ‘Dr’ Brych’s clinic in the Cook Islands.Yet there was never any
coverage of what happened to those patients over subsequent
days and weeks as each and everyone died as a result of their
cancer and possibly the effect of ‘Dr’ Brych’s unusual remedies.
Brych was eventually imprisoned for 6 years in the United States.
Upon release after 3 years he left for Switzerland and has since
changed his name. A report in the Herald Tribune in 1998 had
him in Capetown meeting with another remarkable relic of Perth’s
medical arena: Christo Moll.
Does Perth attract the unusual and alternative in cancer therapy?
Is the media more at fault in Australia than elsewhere for the
‘oxygen’ they provide the individual, alternative practitioners?
Should we include former premier John Tonkin for his stubborn
and irrational promotion of the Tronado and also his introducing
the manufacture and distribution by a state government
department of the extract of Maroon Bush for which, once again,
there was no scientific evidence of any therapeutic benefit? (The
manufacture and distribution of Maroon Bush extract by the
Government’s Chemistry Laboratories continued until 2008 (noone having the political courage to stop it earlier). Even the WA
Poisons Registry was amended in 2008 to allow the therapeutic
use of Laetrile; a decision (endorsed by the Federal Government)
based on compassionate as opposed to scientific grounds. And
in 2000 a world exclusive with a WA medical specialist arrested
and charged with the wilful murder of a 47 year old terminally
ill woman in a Perth hospice. After two appearances before a
Magistrate, a Supreme Court jury found him not guilty. 2005 also
saw unproven caesium chloride treatment apparently result in the
death of several patients, some of whom came from overseas,
which involved police and coronial investigations. And the
internet continues to bring a never ending cascade of products
and therapies to-gether with dramatic claims for therapeutic
purity and benefit. What is missing in all this? A reliable source
of information for the public that is easy to access and kept up
to date.
Such a facility was recommended by the Australian Senate in
June2005 but has never been acted on. Without access to solid,
reliable information cancer patients and their carers will continue
to be tempted to make some very risky and sometimes expensive
decisions.
Waiting for Godot…………
alph Nader claims it takes at least 8 years to achieve any
lasting change in function or policy within any public
institution. He obviously left Australia out in his calculations. It
appears to take much longer than that – at least in the health
sector. Take the setting-up of a comprehensive cancer centre. WA
has had a fragmented array of cancer treatment services. This
was recognised way back in 1987. Of course a Working Party
was set up and after a year a lengthy report recommended that
Sir Charles Gairdener Hospital be developed as a Comprehensive
Cancer Centre with peripheral services at other metropolitan,
suburban and regional hospitals. That was 1988. It is now
2009/10 and Stage 2 of the Charles Gairdener Cancer Centre
is just beginning to be built. But when stage 2 is completed
will it be a genuine (by international standards) Cancer Centre?
Not really. Unless the planned (but uncommitted) Stage 3 is
undertaken - all WA will have is a teaching hospital with cancer
services including radiotherapy. Meanwhile, the Barton Report
of 2008 identified the acute problems for staff and patients at
both RPH Medical Oncology and Sir Charles Gairdener. During the
last state election the Liberals committed $10million towards
temporary improvements to cover the period whilst the Fiona
Stanley Hospital is being built (completion 2013 or 2014?) and
ditto Stage 2 at Sir Charles Gairdener(2012?). Progress has been
at a snail’s pace and whether any temporary improvements are
provided before the Fiona Stanley Hospital eventually opens is
anyone’s guess.
Palliative Care…….
ime has passed since the Cottage Hospice closed its doors; it has
since been remodeled at great expense and is now providing
an excellent service as Milroy Lodge for cancer patients from
regional WA. But what happened to the government commitment
at the time the hospice was closed to provide dedicated palliative
care beds at Joondalup? And are there any dedicated palliative
care beds and staff (hands-on nursing etc) at RPH or Sir Charles
Gairdner? It doesn’t appear so. Yes – more money is possibly being
spent on palliative care from an admin perspective and the reports
look good – but what happens for example at Fremantle, Royal
Perth and other major hospitals after 6pm each Friday? Palliative
Care is also being used as a generic political shield in the ongoing
community debate about euthanasia; it is a convenient mantra for
politicians from all sides who are terrified of having euthanasia
discussed in the Parliament. Meanwhile,too many patients in the
State’s hospitals are not receiving sustained palliative care from
dedicated and trained staff – especially at weekends.
And what of the future?
here have been huge improvements in the treatment of cancer
over the last 20 years and those who are diagnosed in the
future, as the numbers of new cases increase, should benefit from
what research (including clinical trials) has provided plus better
technology and new drugs. But to achieve the best outcomes,
services need to be better co-ordinated (multi-disciplinary care)
and staffed by well trained health professionals. Measurement of
outcomes of treatment in both public and private hospitals and
clinics is essential. Without having data that records what has
happened on each patient’s journey – including quality of lifenothing will really move forward. Multi-disciplinary treatment is
still challenged by a few cancer specialists which is an impediment
to achieving better outcomes, especially in the private sector
where there is a clear lack of organisation and oversight. Nice
new surroundings, plenty of plants and pictures but modern,
sustained multi-disciplinary treatment? Not anywhere near
it. Is there a solution? Accreditation of clinics and services and
Credentialling of the health professionals who work in them has
to be the way to go. The Australian Cancer Network has both
listed as ‘work in progress’; however, resistance to change from
powerful professional organisations is making it hard going. Both
are critically important to improving outcomes, providing GPs with
better referral pathways and allowing patients and carers the
opportunity make fully informed decisions. Western Australia has
all the opportunities to achieve beneficial systemic changes to
existing services in order that the best advantage can be taken
of brand new facilities as and when they are completed. It is an
exciting opportunity. For the sake of consumers and those health
professionals who provide the services I hope that there will be
enthusiastic individuals to provide the leadership.
R
T
T
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10
UÊ potentially high risk of ovarian cancer
Women of high risk, (>1% of the
population) should be offered
appropriate clinical surveillance at a
specialist cancer or genetic clinic. They
may need more frequent screening,
different modalities (including possibly
MRI), and earlier commencement of
screening or genetic counselling. These
women have;
UÊ two second-degree relatives on the
same side of the family, diagnosed
with breast cancer, at least one
before the age of 50
OR
UÊ two first-degree relatives on the
same side of the family, diagnosed
with breast cancer
OR
UÊ one first-degree relative diagnosed
with breast cancer before the age of
50
Women of moderately increased
risk (<4% of the population) may
need screening with mammography
beginning at a younger age or more
often, however the evidence is not clear.
These women have:
For women of average risk (95% of the
population) two-yearly screening should
occur from the age of 50 to the age of
69. Women 40 – 49 and above the age
of 69 may be screened if they attend.
Who should be screened?
Mammography every two years is
recommended for average risk women
aged 50-69.
Department of Health and Ageing – National
screening programs
http://www.cancerscreening.gov.au/
National Breast and Ovarian Cancer Centre
www.nbocc.org.au
References
BreastScreen Australia aims to reduce
mortality and morbidity from breast
cancer by actively recruiting and
screening women aged 50-69 years for
a free mammogram.
Government programs
UÊ Member of a family in which the
presence of a high risk breast cancer
gene mutation has been established.
OR
UÊ one first or second-degree relative
diagnosed with breast cancer at age
45 or younger plus another first or
second-degree relative on the same
side of the family with sarcoma at
age 45 or younger
UÊ breast cancer in a male relative
UÊ Ashkenazi Jewish ancestry
UÊ breast and ovarian cancer in the
same woman
UÊ bilateral breast cancer
UÊ breast cancer diagnosed before
the age of 40
UÊ additional relatives with breast or
ovarian cancer
UÊ two first or second-degree relatives
on the same side of the family
diagnosed with breast or ovarian
cancer plus one or more of the
following features on the same side
of the family:
OR
Department of Health and Ageing – National
screening programs
http://www.cancerscreening.gov.au/
References
The National Cervical Screening Program
aims to reduce incidence and death from
cervical cancer, in a cost-effective manner,
through an organised approach to cervical
screening. The Program encourages
women in the target population to have
regular Pap tests.
Government programs
The cervical cancer vaccine does not
protect against all strains of HPV that
cause cervical cancer so it is still important
for women who have had the vaccine to
continue regular Pap tests.
Women over 70 years of age who have
had two normal Pap tests in the last five
years, do not require further Pap tests.
If a woman over 70 years has never had
a Pap test, or requests a Pap test, they
should be screened.
For women who have had a hysterectomy,
Pap tests are needed if the cervix was not
completely removed; if the woman, prior
to the hysterectomy, had a history of high
grade abnormalities or if the hysterectomy
was performed as part of treatment for a
gynaecological cancer; or if the woman
has never had a Pap test.
All women who have ever been sexually
active should commence having Pap tests
between the ages of 18 to 20 years, or
one to two years after commencing sexual
activity, whichever is later. In some cases,
it may be appropriate to start screening
before 18 years of age
Who should be screened?
Cervical smear (Pap test) every two years
Method and frequency of
screening
Recommendation: Good
evidence for population based
screening.
Recommendation: Good evidence for population based screening.
Method and frequency of
screening
Cervical cancer
Breast cancer
UÊ A family member who has/had a cancer related
to the syndrome of hereditary non-polyposis
colorectal cancer (HNPCC, also known as
Lynch syndrome) including endometrial, ovarian,
stomach, small bowel, renal pelvis or ureter, biliary
tract, or brain cancer.
UÊ Bowel cancer before the age of 50
UÊ Multiple bowel cancers in a family member
UÊ Two or more first-degree or second-degree relatives
on the same side of the family diagnosed with bowel
cancer, plus any of the following high risk features:
UÊ Three or more first-degree relatives or a combination
of first-degree and second-degree relatives on
the same side of the family diagnosed with bowel
cancer.
People at potentially high risk (>1% of the population)
require close surveillance. These people have;
UÊ Two first-degree or one first-degree and one seconddegree relative/s on the same side of the family
with bowel cancer diagnosed at any age (without
potentially high risk features described below).
OR
UÊ One first-degree with bowel cancer diagnosed
before the age of 55 years (without potentially high
risk features described below).
People of moderately increased risk (<2% of the
population) may need screening with colonoscopy
every five years starting at age 50, or at an age 10
years younger than the age of first diagnosis of bowel
cancer in the family (whichever comes first). FOBT may
be offered in the intervening years. These people are
those who have:
For people of average risk (98% of the population), twoyearly screening should occur from the age of 50. In
addition, it is acceptable to offer flexible sigmoidoscopy
every five years.
Who should be screened?
Faecal Occult Blood Screening (FOBT) at least every
two years for average risk people aged over 50.
Method and frequency of screening
Department of Health and Ageing – National screening programs
www.cancerscreening.gov.au
Familial aspects of bowel cancer: A guide for health professionals
(Cancer Council Australia)
www.cancer.org.au/clinicalguidelines
References
The National Bowel Cancer Screening Program aims to
reduce the incidence and death from bowel cancer. It is
currently offering screening to people turning 50, 55 or
65 years of age between January 2008 and December
2010. They will receive a faecal occult blood test in
the post. Those testing positive (i.e blood found) are
encouraged to visit their doctor for follow up testing.
The age groups will be expanded in future policy
announcements
Government programs
UÊ HNPCC, also known as Lynch syndrome: Colonoscopy
every one to two years from age 25, or five years earlier
than the youngest diagnosis in the family (whichever
comes first). FOBT may be offered in alternate years or
to subjects unwilling to accept frequent colonoscopy.
There are options for surveillance at other sites, usually
starting from age 25-35. Prophylactic surgery may be
appropriate for some.
UÊ FAP: Flexible sigmoidoscopy yearly or second
yearly starting from age 12-15 years until polyposis
develops, then prophylactic surgery. If family genetic
testing is inconclusive and no polyposis develops,
sigmoidoscopy reduced to every 3 years after the
age of 35, then change to population screening
if examinations normal to age 55. Prophylactic
surgery eg restorative proctocolectomy is
appropriate for those with proven FAP.
Consider referring those at potential high risk to a
familial cancer service for further risk assessment and
possible genetic testing. They should be referred to a
bowel cancer specialist to plan appropriate surveillance
and management. This may include:
UÊ Member of a family in which a gene mutation that
confers a high risk of bowel cancer has been identified.
UÊ At least one first-degree or second-degree relative
with a large number of adenomas throughout
the large bowel (suspected familial adenomatous
polyposis - FAP).
Recommendation: Good evidence for population based screening.
Bowel (colorectal) cancer
Recommendations for screening and surveillance for specific cancers:
Guidelines for general practitioners.
Method of screening
Ultrasound (abdominal, transvaginal, Doppler) and serum
CA125 have been suggested, however none of these
have the sensitivity or specificity to be recommended as a
screening test.
Who should be screened?
Screening is not recommended for women at average risk
(99% of the population).
Women at potentially high risk of ovarian cancer and
perhaps other cancers comprise 1% of the population
and should be referred to a specialist genetic clinic for
assessment and management. This group comprises
women with the following:
Method and frequency of screening
Regular whole body visual examination of the skin by a
medical practitioner, or by self has been suggested but
there is no conclusive evidence that such examinations are
effective in reducing mortality.
Who should be screened?
There is no conclusive evidence that screening of average
risk people decreases mortality from melanoma.
There is low grade evidence that individuals at high risk
of melanoma could benefit from education to recognise
and document lesions suspicious of melanoma, and to
be regularly checked by a clinician with six-monthly full
body examination supported by total body photography
and dermoscopy as required. High risk individuals are not
well defined but may include combinations of the following
factors: age and sex; history of previous melanoma or
non-melanoma skin cancer; family history of melanoma,
including age of onset and multiplicity of any melanoma
cases; the number of common melanocytic naevi; number
of clinically atypical naevi; skin and hair pigmentation type
and response to sun exposure; and evidence of actinic
skin damage.
Melanoma: An aide memoire to assist diagnosis
www.cancer.org.au/clinicalguidelines
Clinical practice guidelines for the management of melanoma in
Australia and New Zealand
www.cancer.org.au/clinicalguidelines
References
Individuals with known inherited mutations in the genes
encoded by the CDKN2A locus, p16INK4A and p14ARF
have an increased melanoma risk, especially in the
context of a family history of melanoma. Screening for a
mutation in the CDKN2A gene be contemplated only after
a thorough clinical risk assessment by a specialist genetic
or melanoma clinic.
Recommendation: Insufficient evidence for
population based screening.
Recommendation: Insufficient evidence for
population based screening.
Assessment of symptoms that may be ovarian cancer:
A guide for GPs
www.cancer.org.au/clinicalguidelines
Clinical practice guidelines for the management of women with
epithelial ovarian cancer
www.cancer.org.au/clinicalguidelines
References
UÊ A member of a family in which the presence of a high
risk ovarian cancer mutation in a gene such as BRCA1,
BRCA2 or one of the DNA mismatch repair genes, has
been demonstrated.
OR
UÊ Three or more first or second-degree relatives on the
same side of the family diagnosed with any of the
cancers associated with hereditary non-polyposis
colorectal cancer (HNPCC): colorectal cancer
(particularly if diagnosed before the age of 50),
endometrial cancer, ovarian cancer, gastric cancer, and
cancers involving the renal tract;
OR
UÊ breast cancer in a male relative;
UÊ breast and ovarian cancer in the same woman;
UÊ bilateral breast cancer;
UÊ breast cancer diagnosed before the age of 40;
UÊ Two first or second-degree relatives on the same side
of the family diagnosed with breast or ovarian cancer,
especially if one or more of the following features occurs
on the same side of the family:
OR
UÊ One first-degree relative diagnosed with epithelial
ovarian cancer in a family of Ashkenazi Jewish ancestry;
Ovarian cancer
Melanoma
Early detection of prostate cancer in general practice: supporting
patient choice - GP/Patient showcard
www.cancer.org.au/Healthprofessionals/PrimaryCareResources.htm
Andrology Australia position statement on prostate screening
http://www.andrologyaustralia.org/docs/AndrologyAustralia_
PSAposition_webversion_140509.pdf
Cancer Council Australia position statement on prostate screening
www.cancer.org.au/positionstatements
References:
The issue of population screening for prostate cancer
remains controversial, as current evidence suggests
the harms associated with screening outweigh the
benefits. Cancer Council Australia’s position is that in
the absence of direct evidence showing a clear benefit of
population based screening for prostate cancer, a patient
centred approach for individual decisions about testing is
recommended. Ideally this takes the form of an informed,
shared, decision-making process between the doctor
and man, discussing the benefits, risks and uncertainties
of testing, and discussion about treatment options and
side effects. Screening discussions and decisions should
always include and take into account, age and other
individual risk factors such as a family history of the
disease.
Who should be screened?
Digital Rectal Examination (DRE) and Serum Prostate
Specific Antigen (PSA) are used as screening tests,
although the accuracy of these tests is not high. The
likelihood that a man has prostate cancer if his PSA is
above 4ng/ml is about 30% (positive predictive value).
For every 100 men who actually have prostate cancer,
between 10 and 30 will have a PSA below 4ng/ml.
Method and frequency of screening
Men should be informed about prostate cancer and the
pros and cons of testing and from this make an individual
decision based on their personal preferences and
individual risk factors.
Recommendation: Insufficient evidence for
population based screening.
Prostate cancer
Cancer Council Australia position statement on testicular cancer
www.cancer.org.au/positionstatements
References:
Males with undescended testes, gonadal dysgenesis,
Klinefelter’s syndrome, father or identical twin with
testicular cancer, or a history of testicular cancer in the
contralateral testis are at increased risk.
No evidence exists on which to base a recommendation
for or against screening for testicular cancer.
Who should be screened?
Regular palpation of the testes by self or physician is
suggested but there is no evidence that this will decrease
mortality.
Method and frequency of screening
Recommendation: Insufficient evidence for
population based screening.
Testicular cancer
Clinical Practice Guidelines for the Prevention, Diagnosis and
Management of Lung Cancer
www.cancer.org.au/clinicalguidelines
References
There is no evidence that any groups benefit from
screening for lung cancer.
Who should be screened?
Chest X-ray, sputum cytology, spiral CT scanning have
been proposed but there is no evidence that any of these
are effective in reducing mortality.
Method and frequency of screening
Recommendation: Insufficient evidence for
population based screening.
Lung Cancer