Specialist breast cancer nurses' views on implementing a fear of cancer recurrence intervention in practice: a mixed methods study.

INTRODUCTION: Fear of cancer recurrence (FCR) in people with breast cancer affects treatment recovery, quality of life, service utilisation and relationships. Our aim was to investigate how specialist breast cancer nurses (SBCN) respond to their patients' fears of cancer recurrence and analyse SBCN's views about embedding a new psychological intervention, the Mini-AFTERc, into their consultations. METHOD: A mixed methods sequential design was used, informed by normalisation process theory. Phase 1: UK SBCNs were emailed a web-based survey to investigate how breast cancer survivors' FCR is currently identified and managed, and their willingness to utilise the Mini-AFTERc. Phase 2: a purposive sample of respondents (n = 20) were interviewed to augment phase 1 responses, and explore views on the importance of addressing FCR, interest in the Mini-AFTERc intervention, its content, skills required and challenges to delivering the intervention. RESULTS: Ninety nurses responded to the survey. When SBCN's were asked to identify the proportion of patients experiencing FCR in their caseload, there was no consensus on the size of the problem or unmet need. They estimated that 20-100% people experience moderate FCR and 10-70% severe FCR. The interviews identified that clinical conversations are focused primarily on giving information about signs and symptoms of recurrence rather than addressing the psychological aspects of fear. CONCLUSION: Findings indicate wide variability in how FCR was identified, assessed and supported by a sample of UK SBCNs. The introduction of a structured intervention into practice was viewed favourably and has implications for nursing and health professional ways of working in all cancer services.

How does genetic risk information for Lynch syndrome translate to risk management behaviours?

BACKGROUND: There is limited research on why some individuals who have undergone predictive genetic testing for Lynch syndrome do not adhere to screening recommendations. This study aimed to explore qualitatively how Lynch syndrome non-carriers and carriers translate genetic risk information and advice to decisions about risk managment behaviours in the Australian healthcare system. METHODS: Participants of the Australasian Colorectal Cancer Family Registry who had undergone predictive genetic testing for Lynch syndrome were interviewed on their risk management behaviours. Transcripts were analysed thematically using a comparative coding analysis. RESULTS: Thirty-three people were interviewed. Of the non-carriers (n = 16), 2 reported having apparently unnecessary colonoscopies, and 6 were unsure about what population-based colorectal cancer screening entails. Of the carriers (n = 17), 2 reported they had not had regular colonoscopies, and spoke about their discomfort with the screening process and a lack of faith in the procedure's ability to reduce their risk of developing colorectal cancer. Of the female carriers (n = 9), 2 could not recall being informed about the associated risk of gynaecological cancers. CONCLUSION: Non-carriers and female carriers of Lynch syndrome could benefit from further clarity and advice about appropriate risk management options. For those carriers who did not adhere to colonoscopy screening, a lack of faith in both genetic test results and screening were evident. It is essential that consistent advice is offered to both carriers and non-carriers of Lynch syndrome.

iPrevent®: a tailored, web-based, decision support tool for breast cancer risk assessment and management.

We aimed to develop a user-centered, web-based, decision support tool for breast cancer risk assessment and personalized risk management. Using a novel model choice algorithm, iPrevent(®) selects one of two validated breast cancer risk estimation models (IBIS or BOADICEA), based on risk factor data entered by the user. Resulting risk estimates are presented in simple language and graphic formats for easy comprehension. iPrevent(®) then presents risk-adapted, evidence-based, guideline-endorsed management options. Development was an iterative process with regular feedback from multidisciplinary experts and consumers. To verify iPrevent(®), risk factor data for 127 cases derived from the Australian Breast Cancer Family Study were entered into iPrevent(®), IBIS (v7.02), and BOADICEA (v3.0). Consistency of the model chosen by iPrevent(®) (i.e., IBIS or BOADICEA) with the programmed iPrevent(®) model choice algorithm was assessed. Estimated breast cancer risks from iPrevent(®) were compared with those attained directly from the chosen risk assessment model (IBIS or BOADICEA). Risk management interventions displayed by iPrevent(®) were assessed for appropriateness. Risk estimation model choice was 100 % consistent with the programmed iPrevent(®) logic. Discrepant 10-year and residual lifetime risk estimates of >1 % were found for 1 and 4 cases, respectively, none was clinically significant (maximal variation 1.4 %). Risk management interventions suggested by iPrevent(®) were 100 % appropriate. iPrevent(®) successfully integrates the IBIS and BOADICEA risk assessment models into a decision support tool that provides evidence-based, risk-adapted risk management advice. This may help to facilitate precision breast cancer prevention discussions between women and their healthcare providers.

Transitioning to routine breast cancer risk assessment and management in primary care: what can we learn from cardiovascular disease?

To capitalise on advances in breast cancer prevention, all women would need to have their breast cancer risk formally assessed. With ~85% of Australians attending primary care clinics at least once a year, primary care is an opportune location for formal breast cancer risk assessment and management. This study assessed the current practice and needs of primary care clinicians regarding assessment and management of breast cancer risk. Two facilitated focus group discussions were held with 17 primary care clinicians (12 GPs and 5 practice nurses (PNs)) as part of a larger needs assessment. Primary care clinicians viewed assessment and management of cardiovascular risk as an intrinsic, expected part of their role, often triggered by practice software prompts and facilitated by use of an online tool. Conversely, assessment of breast cancer risk was not routine and was generally patient- (not clinician-) initiated, and risk management (apart from routine screening) was considered outside the primary care domain. Clinicians suggested that routine assessment and management of breast cancer risk might be achieved if it were widely endorsed as within the remit of primary care and supported by an online risk-assessment and decision aid tool that was integrated into primary care software. This study identified several key issues that would need to be addressed to facilitate the transition to routine assessment and management of breast cancer risk in primary care, based largely on the model used for cardiovascular disease.

An exploration of the communication patterns and language used between clinical geneticists and parents of children with dysmorphic features.

The present study aims to provide insight into the interactions between clinical geneticists and parents of children with dysmorphic features during syndrome assessment. Seven families attending a dysmorphology clinic for syndrome assessment consented to have their consultation recorded and transcribed verbatim. Content and discourse analyses were used to study the language and communication patterns of problematic and challenging sections of the consultations, primarily sections concerning the child's appearance and diagnosis which were marked by dysfluency and hesitation, indicators of problematic communication. Findings revealed that the clinical geneticists used a range of communicative strategies when discussing a child's appearance, such as comparing the child's features with those of parents or other individuals and minimizing differences. In doing so they displayed an orientation to the "face-threatening" nature of this communicative task. While geneticists discussed the child's appearance in an extremely sensitive manner, parents tended to describe their child's appearance using direct and objective language. These findings provide novel insight into the complexity of syndrome assessment consultations in a dysmorphology clinic. We suggest that parents may be seeking a more open discussion of their child's appearance, and clinician engagement with this may prove a more effective communication strategy than those currently employed, while remaining sensitive to parents' responses to such a discussion. At the start of the consultation it is important to give parents the opportunity to voice their concerns and expectations, and to explain to parents that a diagnosis may not be reached.

Association of Phytophthora with Declining Vegetation in an Urban Forest Environment.

Urban forests consist of various environments from intensely managed spaces to conservation areas and are often reservoirs of a diverse range of invasive pathogens due to their introduction through the nursery trade. Pathogens are likely to persist because the urban forest contains a mixture of native and exotic plant species, and the environmental conditions are often less than ideal for the trees. To test the impact of different land management approaches on the Phytophthora community, 236 discrete soil and root samples were collected from declining trees in 91 parks and nature reserves in Joondalup, Western Australia (WA). Sampling targeted an extensive variety of declining native trees and shrubs, from families known to be susceptible to Phytophthora. A sub-sample was set aside and DNA extracted for metabarcoding using Phytophthora-specific primers; the remaining soil and root sample was baited for the isolation of Phytophthora. We considered the effect on the Phytophthora community of park class and area, soil family, and the change in canopy cover or health as determined through sequential measurements using remote sensing. Of the 236 samples, baiting techniques detected Phytophthora species from 24 samples (18 parks), while metabarcoding detected Phytophthora from 168 samples (64 parks). Overall, forty-four Phytophthora phylotypes were detected. Considering only sampling sites where Phytophthora was detected, species richness averaged 5.82 (range 1-21) for samples and 9.23 (range 2-24) for parks. Phytophthora multivora was the most frequently found species followed by P. arenaria, P. amnicola and P. cinnamomi. While park area and canopy cover had a significant effect on Phytophthora community the R2 values were very low, indicating they have had little effect in shaping the community. Phytophthora cinnamomi and P. multivora, the two most invasive species, often co-occurring (61% of samples); however, the communities with P. multivora were more common than those with P. cinnamomi, reflecting observations over the past decade of the increasing importance of P. multivora as a pathogen in the urban environment.

Patient and community nurse perspectives on recruitment to a randomized controlled trial of urinary catheter washout solutions.

AIM: To give evidence around the acceptability of a proposed randomized controlled trial (RCT) of catheter washout solutions. DESIGN: A sample of senior community nursing staff (N = 7) were interviewed, and four focus groups with a sample of community nurses were conducted. Eleven semi-structured face-to-face interviews were undertaken with patients using a long-term catheter. METHODS: An in-depth qualitative study using a phenomenological approach was employed. This approach was suitable to explore the lived experiences of patients and gain their viewpoints and experiences. RESULTS: Nurse participants raised concerns about the removal of washout treatment or increased risk of infection in relation to which arm of the trial patients were randomized to. There was concern that patients could get used to the increased contact with nursing staff. Six patients who agreed to participate cited personal benefit, benefiting others and a sense of indifference. Four patients were unsure about taking part and one declined. All cited concerns about negative implications for themselves.

Transitioning from phosphate mining to agriculture: Responses to urea and slow release fertilizers for Sorghum bicolor.

Globally, land-use transition from mining to agriculture is becoming increasingly attractive and necessary for many reasons. However, low levels of necessary plant nutrients, and high levels of heavy metals, can hamper plant growth, affecting yield, and potentially, food safety. In post-phosphate mining substrates, for example, nitrogen (N) is a key limiting nutrient, and, although legumes are planted prior to cereals, N supplementation is still necessary. We undertook two field trials on Christmas Island, Australia, to determine whether Sorghum bicolor could be grown successfully in a post-phosphate mining substrate. The first trial investigated N (urea) demand (amount of N required for adequate crop growth) for S. bicolor, and whether N addition could reduce the naturally occurring cadmium (Cd) concentrations in the crop. The second trial examined whether slow release nitrogen fertilizers (SRF) could replace urea to increase biomass and reduce Cd concentrations. Our first trial demonstrated that S. bicolor has a high N demand, with the highest biomass being recorded in the 160kg/ha urea treatment. However, plants treated with 80, 120 and 160kg/ha were not significantly different from one another. After 7weeks of growth, leaf Cd concentrations were significantly lower for all urea treatments compared with the control plants. However, after 23weeks, seed Cd concentrations did not differ across treatments. Our second trial demonstrated that the application of SRF (Macracote® and Sulsync®) and 160kg/ha urea significantly increased biomass above the control plants. There was, however, no treatment response in terms of Cd or N concentrations in the seed at final harvest. Thus, we have shown that N is currently critical for S. bicolor, even following legume cropping, and that high biomass and a significant reduction in Cd can be attained with appropriate levels of urea. Our work has important implications for cereal growth and food safety in post-mining agriculture.

A feasibility study of the Mini-AFTER telephone intervention for the management of fear of recurrence in breast cancer survivors: a mixed-methods study protocol.

BACKGROUND: Fear of recurrence (FoR) is a major concern for patients following treatment for primary breast cancer, affecting 60-99% of breast cancer survivors. Mini-AFTER is a brief intervention developed to address this fear, that breast care nurses are ideally placed to deliver. However, their interest in delivering such an intervention is unknown and crucial to its introduction. This study aims to assess the perceived feasibility of the Mini-AFTER telephone intervention for implementation by breast care nurses to manage moderate levels of fear of recurrence among breast cancer survivors. METHODS: A sequential explanatory mixed-methods design will be used, informed by normalisation process theory (NPT). The design will be guided by the stages of NPT. Specifically, understanding and evaluating the process (implementation) that would enable an intervention, such as the Mini-AFTER, not only to be operationalised and normalised into everyday work (embedded) but also sustained in practice (integration). Phase 1: all members on the UK Breast Cancer Care Nursing Network database (n = 905) will be emailed a link to a web-based survey, designed to investigate how breast cancer survivors' FoR is identified and managed within current services and their willingness to deliver the Mini-AFTER. Phase 2: a purposive sample of respondents (n = 20) will be interviewed to build upon the responses in phase 1 and explore breast care nurses' individual views on the importance of addressing fear of recurrence in their clinical consultations, interest in the Mini-AFTER intervention, the content, skills required and challenges to deliver the intervention. DISCUSSION: This study will provide information about the willingness of breast care nurses (BCNs) to provide a structured intervention to manage fear of recurrence. It will identify barriers and facilitators for effective delivery and inform the future design of a larger trial of the Mini-AFTER intervention.

Physiographical variability in arsenic dynamics in Bangladeshi soils.

Rice plants grown on soils with elevated arsenic have been shown to have increased arsenic content in their grains. To gain a better understanding of the likelihood of high grain arsenic in rice grown in different soils, it is important to understand the factors affecting the bioavailability and mobility of arsenic. Paddy soils from six different physiographic regions of Bangladesh were collected, and diffusive gradients in thin-films (DGT) were used to assess the porewater and solid phase arsenic. While significant differences were identified in total soil arsenic (1.4-9.8mg/kg), porewater arsenic (AsCsoln) (5.6-64.7µg/l), labile arsenic (AsCDGT) (6.3-77.6µg/l), and solid phase pool of arsenic (AsKd) (52-1057l/kg), importantly arsenic resupply capacity was not different between the physiographic regions. All soils had a high ratio of DGT to porewater arsenic (~1), this in conjunction with the porewater arsenic values and the high AsKd values suggesting a large solid phase pool of arsenic capable of contributing towards the resupply/transport of the labile pool of arsenic in the soil porewater. This indicates that there is less difference in soil arsenic availability than might be predicted based solely on total soil arsenic content between the physiographic regions.

The iPrevent Online Breast Cancer Risk Assessment and Risk Management Tool: Usability and Acceptability Testing.

BACKGROUND: iPrevent estimates breast cancer (BC) risk and provides tailored risk management information. OBJECTIVE: The objective of this study was to assess the usability and acceptability of the iPrevent prototype. METHODS: Clinicians were eligible for participation in the study if they worked in primary care, breast surgery, or genetics clinics. Female patients aged 18-70 years with no personal cancer history were eligible. Clinicians were first familiarized with iPrevent using hypothetical paper-based cases and then actor scenarios; subsequently, they used iPrevent with their patients. Clinicians and patients completed the System Usability Scale (SUS) and an Acceptability questionnaire 2 weeks after using iPrevent; patients also completed measures of BC worry, anxiety, risk perception, and knowledge pre- and 2 weeks post-iPrevent. Data were summarized using descriptive statistics. RESULTS: The SUS and Acceptability questionnaires were completed by 19 of 20 clinicians and 37 of 43 patients. Usability was above average (SUS score >68) for 68% (13/19) clinicians and 76% (28/37) patients. The amount of information provided by iPrevent was reported as "about right" by 89% (17/19) clinicians and 89% (33/37) patients and 95% (18/19) and 97% (36/37), respectively, would recommend iPrevent to others, although 53% (10/19) clinicians and 27% (10/37) patients found it too long. Exploratory analyses suggested that iPrevent could improve risk perception, decrease frequency of BC worry, and enhance BC prevention knowledge without changing state anxiety. CONCLUSIONS: The iPrevent prototype demonstrated good usability and acceptability. Because concerns about length could be an implementation barrier, data entry has been abbreviated in the publicly available version of iPrevent.

The Experience of Extended Bowel Resection in Individuals With a High Metachronous Colorectal Cancer Risk: A Qualitative Study.

PURPOSE/OBJECTIVES: To ascertain individual experiences of extended bowel resection as treatment for colorectal cancer (CRC) in those with a high metachronous CRC risk, including the self-reported adequacy of information received at different time points of treatment and recovery.
. RESEARCH APPROACH: Qualitative.
. SETTING: Participants were recruited through the Australasian Colorectal Cancer Family Registry and two hospitals in Melbourne, Australia.
. PARTICIPANTS: 18 individuals with a high metachronous CRC risk who had an extended bowel resection from 6-12 months ago.
. METHODOLOGIC APPROACH: Semistructured interviews. Data were analyzed thematically.
. FINDINGS: In most cases, the treating surgeon decided on the best option regarding surgical treatment. Participants felt well informed about the surgical procedure. Information related to surgical outcomes, recovery, and lifestyle adjustment from surgery was not always adequate. Many participants described ongoing worry about developing another cancer. 
. CONCLUSIONS: Patients undergoing an extended resection to reduce metachronous CRC risk require detailed information delivered at more than one time point and relating to several different aspects of the surgical procedure and its outcomes.
. INTERPRETATION: An increased emphasis should be given to the provision of patient information on surgical outcomes, recovery, and lifestyle adjustment. Colorectal nurses could provide support for some of the reported unmet needs.

Assessing and managing breast cancer risk: clinicians' current practice and future needs.

Decision support tools for the assessment and management of breast cancer risk may improve uptake of prevention strategies. End-user input in the design of such tools is critical to increase clinical use. Before developing such a computerized tool, we examined clinicians' practice and future needs. Twelve breast surgeons, 12 primary care physicians and 5 practice nurses participated in 4 focus groups. These were recorded, coded, and analyzed to identify key themes. Participants identified difficulties assessing risk, including a lack of available tools to standardize practice. Most expressed confidence identifying women at potentially high risk, but not moderate risk. Participants felt a tool could especially reassure young women at average risk. Desirable features included: evidence-based, accessible (e.g. web-based), and displaying absolute (not relative) risks in multiple formats. The potential to create anxiety was a concern. Development of future tools should address these issues to optimize translation of knowledge into clinical practice.