Depression and Long-Term Prescription Opioid Use and Opioid Use Disorder: Implications for Pain Management in Cancer.

OPINION STATEMENT: Preventing depression in cancer patients on long-term opioid therapy should begin with depression screening before opioid initiation and repeated screening during treatment. In weighing the high morbidity of depression and opioid use disorder in patients with chronic cancer pain against a dearth of evidence-based therapies studied in this population, patients and clinicians are left to choose among imperfect but necessary treatment options. When possible, we advise engaging psychiatric and pain/palliative specialists through collaborative care models and recommending mindfulness and psychotherapy to all patients with significant depression alongside cancer pain. Medications for depression should be reserved for moderate to severe symptoms. We recommend escitalopram/citalopram or sertraline among selective serotonin reuptake inhibitors (SSRIs), or the serotonin and norepinephrine reuptake inhibitors (SNRIs) duloxetine, venlafaxine, or desvenlafaxine if patients have a significant component of neuropathic pain or fibromyalgia. Tricyclic antidepressants (TCAs) (consider nortriptyline or desipramine, which have better anticholinergic profiles) should be considered for patients who do not respond to or tolerate SSRI/SNRIs. Existing evidence is inadequate to definitively recommend methylphenidate or novel agents, such as ketamine or psilocybin, as adjunctive treatments for cancer-related depression and pain. Physicians who treat patients with cancer pain should utilize universal precautions to limit the risk of non-medical opioid use (non-medical opioid use). Patients should be screened for non-medical opioid use behaviors at initial consultation and at regular intervals during treatment using a non-judgmental approach that reduces stigma. Co-management with an addiction specialist may be indicated for patients at high risk of non-medical opioid use and opioid use disorder. Buprenorphine and methadone are indicated for the treatment of opioid use disorder, and while they have not been systematically studied for treatment of opioid use disorder in patients with cancer pain, they do provide analgesia for cancer pain. While an interdisciplinary team approach to manage psychological stress may be beneficial, this may not be possible for patients treated outside of comprehensive cancer centers.

Quantifying the hospital and emergency department costs for women diagnosed with breast cancer in Queensland.

PURPOSE: With increasing rates of cancer survival due to advances in screening and treatment options, the costs of breast cancer diagnoses are attracting interest. However, limited research has explored the costs to the Australian healthcare system associated with breast cancer. We aimed to describe the cost to hospital funders for hospital episodes and emergency department (ED) presentations for Queensland women with breast cancer, and whether costs varied by demographic characteristics. METHODS: We used a linked administrative dataset, CancerCostMod, limited to all breast cancer diagnoses aged 18 years or over in Queensland between July 2011 and June 2015 (n = 13,285). Each record was linked to Queensland Health Admitted Patient Data Collection and Emergency Department Information Systems records between July 2011 and June 2018. The cost of hospital episodes and ED presentations were determined, with mean costs per patient modelled using generalised linear models with a gamma distribution and log link function. RESULTS: The total cost to the Queensland healthcare system from hospital episodes for female breast cancer was AUD$309 million and AUD$12.6 million for ED presentations during the first 3 years following diagnosis. High levels of costs and service use were identified in the first 6 months following diagnosis. Some significant differences in cost of hospital and ED episodes were identified based on demographic characteristics, with Indigenous women and those from lower socioeconomic backgrounds having higher costs. CONCLUSION: Hospitalisation costs for breast cancer in Queensland exert a high burden on the healthcare system. Costs are higher for women during the first 6 months from diagnosis and for Indigenous women, as well as those with underlying comorbidities and lower socioeconomic position.

Evaluation of a school-based participatory intervention to improve school environments using the Consolidated Framework for Implementation Research.

BACKGROUND: Participatory research offers a promising approach to addressing health inequities and improving the social determinants of health for diverse populations of adolescents. However, little research has systematically explored factors influencing the implementation of participatory health interventions targeting health disparities. OBJECTIVE: This study examined the utility of the Consolidated Framework for Implementation Research (CFIR) in identifying and comparing barriers and facilitators influencing implementation of participatory research trials by employing an adaptation of the CFIR to assess the implementation of a multi-component, urban public school-based participatory health intervention. METHODS: We collected qualitative data over a one-year period through weekly team meeting observational field notes and regular semi-structured interviews with five community-based participatory researchers, one school-based partner, and four school principals involved in implementing a participatory intervention in five schools. Adapted CFIR constructs guided our largely deductive approach to thematic data analysis. We ranked each of the three intervention components as high or low implementation to create an overall implementation effectiveness score for all five schools. Cross-case comparison of constructs across high and low implementation schools identified constructs that most strongly influenced implementation. RESULTS: Ten of 30 assessed constructs consistently distinguished between high and low implementation schools in this participatory intervention, with five strongly distinguishing. Three additional constructs played influential, though non-distinguishing, roles within this participatory intervention implementation. Influential constructs spanned all five domains and fit within three broad themes: 1) leadership engagement, 2) alignment between the intervention and institutional goals, priorities, demographics, and existing systems, and 3) tensions between adaptability and complexity within participatory interventions. However, the dynamic and collaborative nature of participatory intervention implementation underscores the artificial distinction between inner and outer settings in participatory research and the individual behavior change focus does not consider how relationships between stakeholders at multiple levels of participatory interventions shape the implementation process. CONCLUSIONS: The CFIR is a useful framework for the assessment of participatory research trial implementation. Our findings underscore how the framework can be readily adapted to further strengthen its fit as a tool to examine project implementation in this context.

Enhancing integrated psychosocial oncology through leveraging the oncology social worker's role in collaborative care.

OBJECTIVE: The collaborative care model is effective in delivering evidence-based psychosocial oncology care. Social workers comprise the largest proportion of psychosocial oncology providers in the United States. This study describes the process and perceptions of clinical oncology social workers at a large comprehensive cancer center who transitioned to practicing as care managers within collaborative care. METHODS: We describe the process of engaging clinical oncology social workers as care managers as part of the implementation of collaborative care at the Seattle Cancer Care Alliance. We then present survey results from 2017 and 2020 of participating social workers' perceptions of the collaborative care model's advantages and disadvantages. RESULTS: Since the implementation of collaborative care at our institution, key functions of the social worker as care manager were defined. The majority of social workers surveyed in 2017 and 2020 agreed that collaborative care led to improved clinical outcomes, timely access to care, and greater patient satisfaction. They also reported professional advantages: more interdisciplinary team integration, working at the top of their licensure, and improved job satisfaction. Challenges identified included missing important patient needs and creating extra work burden for social workers. CONCLUSIONS: Oncology social workers can be successfully deployed as care managers within a collaborative care model, thus leveraging existing clinical staff to address unmet psychosocial patient needs. This model is feasible and sustainable in a large academic cancer center, requires minimal additional resources, and is favorably viewed by participating social workers in terms of perceived benefits to patients and their own professional roles.

Patient co-payments for women diagnosed with breast cancer in Australia.

PURPOSE: Among Australian women, breast cancer is the most commonly diagnosed cancer. The out-of-pocket cost to the patient is substantial. This study estimates the total patient co-payments for Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) for women diagnosed with breast cancer and determined the distribution of these costs by Indigenous status, remoteness, and socioeconomic status. METHODS: Data on women diagnosed with breast cancer in Queensland between 01 July 2011 and 30 June 2012 were obtained from the Queensland Cancer Registry and linked with hospital and Emergency Department Admissions, and MBS and PBS records for the 3 years post-diagnosis. The data were then weighted to be representative of the Australian population. The co-payment charged for MBS services and PBS prescriptions was summed. We modelled the mean co-payment per patient during each 6-month time period for MBS services and PBS prescriptions. RESULTS: A total of 3079 women were diagnosed with breast cancer in Queensland during the 12-month study period, representing 15,335 Australian women after weighting. In the first 3 years post-diagnosis, the median co-payment for MBS services was AU$ 748 (IQR, AU$87-2121; maximum AU$32,249), and for PBS prescriptions was AU$ 835 (IQR, AU$480-1289; maximum AU$5390). There were significant differences in the co-payments for MBS services and PBS prescriptions by Indigenous status and socioeconomic disadvantage, but none for remoteness. CONCLUSIONS: Women incur high patient co-payments in the first 3 years post-diagnosis. These costs vary greatly by patient. Potential costs should be discussed with women throughout their treatment, to allow women greater choice in the most appropriate care for their situation.

Long-term out of pocket expenditure of people with cancer: comparing health service cost and use for indigenous and non-indigenous people with cancer in Australia.

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

Labour force participation and the cost of lost productivity due to cancer in Australia.

BACKGROUND: In Australia, 40% of people diagnosed with cancer will be of working age (25-64 years). A cancer diagnosis may lead to temporary or permanent changes in a person's labour force participation, which has an economic impact on both the individual and the economy. However, little is known about this economic impact of cancer due to lost productivity in Australia. This paper aims to determine the labour force participation characteristics of people with cancer, to estimate the indirect cost due to lost productivity, and to identify any inequality in the distribution of labour force absence in Australia. METHODS: This study used national cross-sectional data from the 2015 Survey of Disability, Ageing and Carers, conducted by the Australian Bureau of Statistics (ABS). The ABS weighted each component of the survey to ensure the sample represented the population distribution of Australia. The analysis was limited to people aged 25-64 years. Participants were assigned to one of three health condition groups: 'no health condition', 'cancer', and 'any other long-term health condition'. A series of logistic regression models were constructed to determine the association between health condition and labour force participation. RESULTS: A total of 34,393 participants surveyed were aged 25-64 years, representing approximately 12,387,800 Australians. Almost half (46%) of people with cancer were not in the labour force, resulting in a reduction of $1.7 billion to the Australian gross domestic product (GDP). Amongst those in the labour force, people with no health condition were 3.00 times more likely to be employed full-time compared to people with cancer (95% CI 1.96-4.57), after adjusting for age, sex, educational attainment and rurality. Amongst those with cancer, people without a tertiary qualification were 3.73 times more likely to be out of the labour force (95% CI 1.97-7.07). CONCLUSIONS: This paper is the first in Australia to estimate the national labour force participation rates of people with cancer. People with cancer were less likely to be in the labour force, resulting in a reduction in Australia's GDP. Cancer survivors, especially those without a tertiary qualification may benefit from support to return to work after a diagnosis.

A qualitative study of treatment needs among pregnant and postpartum women with substance use and depression.

Little is known about treatment for pregnant and postpartum women with co-occurring substance use and depression. Funded by the National Institute of Drug Abuse, we conducted three focus groups with 18 pregnant and postpartum women in 2011 at an urban substance use treatment clinic. A semi-structured discussion guide probed for factors impacting treatment outcomes and needs. Data were analyzed using grounded theory. Women identified motivational, family, friend, romantic, and agency characteristics as facilitative or challenging to their recoveries, and desired structure (group treatment, a safe environment, and transportation) and content (attention to mental health, family, and gender-specific issues) of treatment.

Medication reconciliation and discharge communication from hospital to general practice: a quantitative analysis.

BACKGROUND: The aim of this study was to assess the quality of effective discharge communication to primary practice from a hospital that uses ieMR (integrated electronic Medical Record), a complete electronic prescribing/medical record platform. METHODS: A retrospective quantitative analysis of 232 discharge encounters from a major tertiary hospital assessed the discharge summary quality; timeliness, completeness and medication information. RESULTS: Median time to discharge summary was 1day. 22.0% of discharge summaries were incomplete at 30days post discharge and 44.5% of discharge summaries were incomplete at 30days post discharge if discharged on a weekend compared to weekday (P -value=0.001). Rates of medication reconciliation were completed at approximately 35% at each point of the patient stay and 56.9% of patients had a GP discharge summary listing discharge medications. However, if certain progressive steps were completed (i.e. Home Medications recorded in ieMR, Discharge Reconciliation in ieMR, and Patient Discharge Medication Record in eLMs (Enterprise-wide Liaison Medication System)), then, the 'Medications on Discharge' was significantly more likely to be present in the discharge summary, at rates of 70.1%, 85.9%, and 98.6% respectively (P -value=0.007, <0.001, <0.001). Conversely not doing these steps dropped rates of having medications listed in the discharge summary to 50.0%, 40.3% and 34.1% respectively. CONCLUSIONS: This study assessed current discharge summary quality since the introduction of electronic medical records. It demonstrated the significant value of correct use of electronic programs, including performing all crucial steps of reconciliation. Targeted interventions in future studies that rectify the shortfalls in discharge communication are warranted.

Australian general practitioners' views on qualities that make effective discharge communication: a scoping review.

Transitions of patient care between hospital discharge and primary care are known to be an area of high-risk where communication is imperative for patient safety. Discharge summaries are known to often be incomplete, delayed and unhelpful for community healthcare providers. The aim of this review was to identify and map the literature which discusses Australian general practitioners' (GPs) views on the qualities that make up effective discharge communication. Medline, Scopus and the Cochrane register of controlled drug trails and systematic reviews were searched for publications until October 2021 that discussed Australian GPs' views on discharge communication from hospital to general practice. Of 1696 articles identified, 18 met inclusion and critical appraisal criteria. Five studies identified that GPs view timeliness of discharge summary receipt to be a problem. Communication of medication information in the discharge summary was discussed in six studies, with two reporting that GPs view reasons for medication changes to be essential. Five studies noted GPs would prefer to receive clinical discipline or diagnosis specific information. Four studies identified that GPs viewed the format and readability of discharge summaries to be problematic, with difficulties finding salient information. The findings of this scoping review indicate that GPs view timeliness, completeness, readability, medication related information and diagnosis/clinical discipline specific information to be qualities that make up effective discharge communication from hospital to the community. There are opportunities for further research in perspectives of effective discharge communication, and future studies on interventions to improve discharge communication, patient safety and policy in transfers of care.

Evaluating the quality and safety of the BreastScreen remote radiology assessment model of service delivery in Australia.

INTRODUCTION: Breast cancer is the most commonly diagnosed cancer in Australian women. Given the diverse geography and populations within Australia, the ability to offer a telemedicine-supported breast screening and assessment service may increase access. The aim of this study was to assess clinical outcomes of a telemedicine-based remote radiology assessment service delivery model for detecting breast cancer in regional Australian women compared to the traditional radiologist onsite model. METHODS: This study was a pre-post intervention study using de-identified administrative data. Data were collected from seven sites across three health jurisdictions within Australia. There were a total of 21,117 assessment visits, with 10,508 (49.8%) pre- and 10,609 (50.2%) post-remote model implementation. Of the 10,609 post-remote model visits, 3,904 (36.8%) were under the remote model. The main outcome was cancer detection, split into any cancer, any invasive cancer or any small invasive cancer. Timeliness of assessment was also examined. RESULTS: After adjusting for multiple factors, there were no statistically significant differences in cancer detection rates between the remote and onsite models (adjusted odds ratio (AOR) = 1.02, 95% CI 0.86-1.19, n.s.). Implementing the remote assessment model had statistically significant positive effects on the timeliness of assessment (AOR = 0.68, 95% CI 0.59-0.77, p < 0.001). DISCUSSION: This study found the remote model delivers safe and high-quality assessment services, with equivalent rates of cancer detection and improved timeliness of assessment when compared to the traditional onsite model. Careful monitoring and ongoing evaluation of any health-service model is important for ongoing safety, efficiency and acceptability.

Applying a Race(ism)-Conscious Adaptation of the CFIR Framework to Understand Implementation of a School-Based Equity-Oriented Intervention.

Objectives: To use the Consolidated Framework for Implementation Research (CFIR) adapted to a race-conscious frame to understand ways that structural racism interacts with intervention implementation and uptake within an equity-oriented trial designed to enhance student-school connectedness. Design: Secondary analysis of qualitative implementation data from Project TRUST (Training for Resiliency in Urban Students and Teachers), a hybrid effectiveness-implementation, community-based participatory intervention. Setting: Ten schools across one urban school district. Methods: We analyzed qualitative observational field notes, youth and parent researcher reflections, and semi-structured interviews with community-academic researchers and school-based partners within CFIR constructs based on framing questions using a Public Health Critical Race Praxis approach. Results: Within most CFIR constructs and sub-constructs, we identified barriers to implementation uptake not previously recognized using standard race-neutral definitions. Themes that crossed constructs included: 1) Leaders' willingness to examine Black, Indigenous, People of Color (BIPOC) student and parent experiences of school discrimination and marginalization had a cascading influence on multiple factors related to implementation uptake; 2) The race/ethnicity of the principals was related to intervention engagement and intervention uptake, particularly at the extremes, but the relationship was complex; 3) External change agents from BIPOC communities facilitated intervention uptake in indirect but significant ways; 4) Highly networked implementation champions had the ability to enhance commitment to intervention uptake; however, perceptions of these individuals and the degree to which they were networked was highly racialized. Conclusions: Equity-oriented interventions should consider structural racism within the CFIR model to better understand intervention uptake.

Lessons Learned in Implementing Youth and Parent Participatory Action Research in a School-Based Intervention.

BACKGROUND: Participatory action research (PAR) empowers youth and parent stakeholders to address school connectedness and school environment inequities to improve educational social determinants of health. OBJECTIVES: To identify lessons learned when implementing school-based youth and parent PAR (YPAR and PPAR) targeting health and academic outcomes for Indigenous students and students of color. METHODS: We collected data from five community-academic research team members who coordinated YPAR and PPAR implementation across five middle and high schools and used thematic analysis with deductive and inductive coding to identify contributors to successful PAR implementation. RESULTS: Experiential learning strengthened youth and parent researcher skills and maintained their engagement, community-building supported the PAR process, PAR required support from facilitators with diverse skill sets, and individuals in bridging roles positioned researchers for success within institutions. CONCLUSIONS: PAR holds promise for application in other settings to address institutional change and social determinants of health.

Correction to: CancerCostMod: a model of the healthcare expenditure, patient resource use, and patient co-payment costs for Australian cancer patients.

Following publication of the original article [1], the authors reported errors on their article.

The patient co-payment and opportunity costs of accessing healthcare for Indigenous Australians with cancer: A whole of population data linkage study.

AIM: To quantify the direct out-of-pocket patient co-payments and time opportunity costs (length of hospital stay) incurred by Indigenous and non-Indigenous persons diagnosed with cancer during the first year postdiagnosis. METHODS: CancerCostMod was used, which is a model of cancer costs based upon a whole-of-population data linkage. The base population was a census of all persons diagnosed with cancer in Queensland, Australia between 1 July 2011 and 30 June 2012 (n = 25,553). Individual records were linked to corresponding Queensland Health Admitted Patient Data Collection, Emergency Data Information System, Medicare Benefits Schedule, and Pharmaceutical Benefits Scheme records between 1 July 2011 and 30 June 2015. Queensland data were weighted to be representative of the Australian population (approximately 123,900 Australians, 1.7% Indigenous Australians). RESULTS: After adjusting for age, sex, rurality, area-based deprivation, and cancer group, Indigenous Australians accrued significantly less in postdiagnosis patient co-payments at 0-6 months (61% less) and 7-12 months (63% less). Indigenous Australians also had significantly fewer postdiagnosis hospitalizations at 0-6 months (21% fewer) and 7-12 months (27% fewer). CONCLUSION: There is growing concern regarding the financial burden of cancer to the patient. The time spent away from family and their community may also have an important time opportunity cost, which may affect a person's decision to undertake or continue treatment. This is the first study in Australia to identify the financial cost of co-payments for Indigenous people with cancer, as well as the number and length of hospitalizations as drivers of time opportunity costs.

CancerCostMod: a model of the healthcare expenditure, patient resource use, and patient co-payment costs for Australian cancer patients.

Although cancer survival in general has improved in Australia over the past 30 years, Indigenous Australians, socioeconomically disadvantaged persons, and people living in remote areas still experience poorer health outcomes. This paper aims to describe the development of CancerCostMod, and to present the healthcare expenditure and patient co-payments for the first 12-months post-diagnosis. The base population is a census of all cancer diagnoses (excluding non-melanoma skin cancer) in Queensland, Australia between 1 July 2011 and 30 June 2012 (N = 25,553). Each individual record was linked to their Queensland Health Admitted Patient Data Collection, Emergency Department Information System, Medicare Benefits Schedule, and Pharmaceutical Benefits Scheme records from 1 July 2011 to 30 June 2015. Indigenous status was recorded for 87% of participants in our base population. Multiple imputation was used to assign Indigenous status to records where Indigenous status was missing. This base population was then weighted, using a programmed SAS macro (GREGWT) to be representative of the Australian population. We adopted a national healthcare perspective to estimate the cost of cancer for hospital episodes, ED presentations, primary healthcare, and prescription pharmaceuticals. We also adopted an individual perspective, to estimate the primary healthcare and prescription pharmaceutical patient co-payments. Once weighted, our sample represents approximately 123,900 Australians (1.7% Indigenous Australians). The total healthcare system cost of all cancers during the first 12-months post diagnosis was $4.8 billion, [corrected] and patient co-payments costs were $127 million. After adjusting for sex, age at diagnosis, Indigenous status, rurality, socioeconomic status, and broad cancer type, significant differences in costs were observed for population groups of interest within the first year post-diagnosis. This paper provides a more recent national estimate of the cost of cancer, and addresses current research gaps by highlighting the distribution of healthcare and individual costs by Indigenous status, rurality, and socioeconomic status.

Advocacy for malaria prevention, control, and research in the twenty-first century.

Until recent years, public interest and political investment in malaria prevention, control, and research have been stagnant. The global malaria agenda is now experiencing an unprecedented time of public and political will and momentum. At the heart of this favorable period lies a nascent, but increasingly sophisticated, global advocacy effort that has contributed to new and expanded malaria funding, programs, and technology. This paper reviews the elements of malaria's rise to political and public prominence, tracks the increase in funding and policy commitments to malaria over the past decade, and comments on an evolving policymaking progress, increasing transparency and accountability in program governance, and the impact of philanthropic investments in malaria advocacy. In addition, the principles of sound advocacy are described along with the mechanisms that will underlie sustained pro-political momentum for malaria research, resources, and results. "Today, we have begun to write the final chapter in the history of malaria. We have raised hopes and expectations of our people--we must not let them down. We cannot afford to let them down." --His Excellency Olusegan Obasanjo, President of Nigeria, Abuja Summit 2000.

Quantifying Queensland patients with cancer health service usage and costs: study protocol.

INTRODUCTION: The overall mortality rate for cancer has declined in Australia. However, socioeconomic inequalities exist and the out-of-pocket costs incurred by patients in Australia are high compared with some European countries. There is currently no readily available data set to provide a systematic means of measuring the out-of-pocket costs incurred by patients with cancer within Australia. The primary aim of the project is to quantify the direct out-of-pocket healthcare expenditure of individuals in the state of Queensland, who are diagnosed with cancer. METHODS AND ANALYSIS: This project will build Australia's first model (called CancerCostMod) of out-of-pocket healthcare expenditure of patients with cancer using administrative data from Queensland Cancer Registry, for all individuals diagnosed with any cancer in Queensland between 1 July 2011 and 30 June 2012, linked to their Admitted Patient Data Collection, Emergency Department Information System, Medicare Benefits Schedule and Pharmaceutical Benefits Scheme records from 1 July 2011 to 30 June 2015. No identifiable information will be provided to the authors. The project will use a combination of linear and logistic regression modelling, Cox proportional hazards modelling and machine learning to identify differences in survival, total health system expenditure, total out-of-pocket expenditure and high out-of-pocket cost patients, adjusting for demographic and clinical confounders, and income group, Indigenous status and geographic location. Results will be analysed separately for different types of cancer. ETHICS AND DISSEMINATION: Human Research Ethics approval has been obtained from the Townsville Hospital and Health Service Human Research Ethics Committee (HREC/16/QTHS/110) and James Cook University Human Research Ethics Committee (H6678). Permission to waive consent has been sought from Queensland Health under the Public Health Act 2005.

Sun-Protective Behaviors of Student Spectators at Inter-school Swimming Carnivals in a Tropical Region Experiencing High Ambient Solar Ultraviolet Radiation.

Skin cancer is the most common cancer in humans and Australia (particularly in Queensland) has the highest incidence globally. Sunlight is a known skin carcinogen and reflects off water, exacerbating the risk of sunburn. In 1988, the "SunSmart Program" was developed to promote sun-protection to Australian children. Within a decade, it evolved to include a voluntary national accreditation program for schools, known as the SunSmart Schools (SSS) Program. Additionally, in 2008, it became compulsory for primary schoolchildren attending Queensland government-funded schools to wear a shirt during all water-based activities, except when competing. We observed the proportion of student spectators from 41 Townsville (latitude 19.3°S) primary schools (65.9% SSS) wearing hats at inter-school swimming carnivals in 2009-2011 and 2015 and the proportion wearing a shirt. Overall, a median of 30.7% student spectators from each school wore a hat [max 46.2% (2009); min 18% (2015)] and 77.3% wore a shirt [max 95.8% (2009); min 74.5% (2015)], suggesting that hats are under-utilized. Students from non-government (private) schools were twice as likely as students from government schools to wear a hat (41 vs. 18.2% p = 0.003). Neither the hat nor the shirt-wearing behaviors of student spectators were significantly influenced by their school's size (number of students), educational advantage, sun-protection policy score, or SunSmart status, indicating that other socioeconomic factors, not assessed here, may have influenced the results. Our findings suggest that the mandatory swim-shirt policy introduced in 2008 was very effective, especially initially. However, monitoring and feedback of results to schools may be needed to maintain high levels of compliance in the longer-term. Schoolchildren attending swimming carnivals should not rely on sunscreen or shade alone to protect against direct and reflected-sunlight, and need prompting to put a hat and shirt back on immediately after a race. This responsibility could be delegated to either a parent or a student prefect, if teachers are too busy to encourage and monitor sun-safety compliance among the students in their care.