Oncological outcomes in an Australian cohort according to the new prostate cancer grading groupings.

BACKGROUND: A new 5-tiered grading grouping system has recently been endorsed for reporting of prostate cancer (PCa) grade to better reflect escalating risk of progression and cancer death. While several validations of the new grade groupings have been undertaken, most have involved centralised pathological review by specialist urological pathologists. METHODS: Participants included 4268 men with non-metastatic PCa diagnosed between 2006 and 2013 from the multi-institutional South Australia Prostate Cancer Clinical Outcomes Collaborative registry. PCa-specific survival and biochemical recurrence-free survival were compared across the five grade groups using multivariable competing risk regression. RESULTS: For the entire cohort, risk of PCa death increased with increasing grade groups (at biopsy) Adjusted subdistribution-hazard ratios [sHR] and 95% confidence intervals [95%CI] were: 2.2 (1.5-3.6); 2.5 (1.6-4.2); 4.1 (2.6-6.7) and 8.7 (4.5-14.0) for grade groups II (pattern 3 + 4), III (pattern 4 + 3), IV (total score 8) and V (total score 9-10) respectively, relative to grade group I (total score < =6). Clear gradients in risk of PCa death were observed for radical prostatectomy (RP), but were less clear for those who had radiotherapy (RT) with curative intent and those who were managed conservatively. Likewise, risk of biochemical recurrence increased across grade groups, with a strong and clear gradient for men undergoing RP [sHR (95%CI): 2.0 (1.4-2.8); 3.8 (2.9-5.9); 5.3 (3.5-8.0); 11.2 (6.5-19.2) for grade groups II, III, IV and V respectively, relative to grade group I], and a less clear gradient for men undergoing RT. CONCLUSION: In general, the new five-tiered grade groupings distinguished PCa survival and recurrence outcomes for men with PCa. The absence of a clear gradient for RT may be due to heterogeneity in this patient group.

Realising opportunities for evidence-based cancer service delivery and research: linking cancer registry and administrative data in Australia.

The traditional roles of Australian cancer registries have been incidence, mortality and survival surveillance although increasingly, roles are being broadened to include data support for health-service management and evaluation. In some Australian jurisdictions, cancer stage and other prognostic data are being included in registry databases and this is being facilitated by an increase in structured pathology reporting by pathology and haematology laboratories. Data linkage facilities are being extended across the country at national and jurisdictional level, facilitating data linkage between registry data and data extracts from administrative databases that include treatment, screening and vaccination data, and self-reported data from large population cohorts. Well-established linkage protocols exist to protect privacy. The aim is to gain better data on patterns of care, service outcomes and related performance indicators for health-service management and population health and health-services research, at a time of increasing cost pressures. Barriers include wariness among some data custodians towards releasing data and the need for clearance for data release from large numbers of research ethics committees. Progress is being made though, and proof of concept is being established.

What factors affect the odds of NSW cancer patients presenting with localised as opposed to more advanced cancer?

OBJECTIVE: The purpose was to examine the odds of presenting with localised as opposed to more advanced cancer by place of residence to gain evidence for planning early detection initiatives. METHODS: Design, settings and participant's cases of invasive cancer reported to the NSW population-based Cancer Registry for the 1980-2008 diagnostic periods. Main outcome measure(s) between 1980 and 2008, 293,848 of reported cases (40.2%), had localised cancer at diagnosis. Logistic regression analysis was undertaken to determine the odds of localised cancer by place of residence for all cancers sites combined while adjusting for age, sex, period of diagnosis, socioeconomic status, migrant status and prognosis (as inferred from cancer type). RESULTS: Multivariate logistic regression analysis indicated that patients from rural areas were less likely than urban patients to present with localised cancer after adjusting for other socio-demographic factors and prognosis by cancer type (regardless of how rurality was classified). The difference ranged from 4% for remote (OR = 0.96, 95% CI 0.95-0.98) to 14% (OR = 0.86, 95% CI 0.79-0.84) for very remote compared with highly accessible areas. It is estimated that a maximum of 4,205 fewer cases of localised cancer occurred in patients from rural areas over the study period than expected from the stage distribution for urban patients. Residents aged between 30 and 74 years of age at diagnosis and those living in high socioeconomic status areas were more likely to present with localised cancer. By contrast, people aged 75 years or older at diagnosis, migrants from non-English-speaking countries and people diagnosed in more recent diagnostic periods were less likely to present with localised cancer. CONCLUSIONS: Targeted strategies that specifically encourage earlier diagnosis and treatment that may subsequently influence better survival are required to increase the proportion of NSW residents presenting with localised cancer at diagnosis.

Clinical and pathological factors predictive of lymph node status in women with screen-detected breast cancer.

Two thousand one hundred and thirty five asymptomatic invasive breast cancers detected through screening mammography were analysed to identify predictors of lymph node involvement. Multivariable analysis indicated that predictors included larger tumour diameter, an infiltrating ductal or lobular histological type, multifocal disease, a palpable lesion, and a younger age at diagnosis. An association also was found between nodal involvement and the presence of an extensive in situ component (EIC). Grade was associated with nodal involvement as a univariate predictor. It would be more accurate for screening assessment clinics to use models for predicting nodal status that were customised to their own experience rather than generic models developed in other settings that related predominantly to symptomatic cancer. These models could assist clinical decision-making on axillary node dissection and give guidance to pathologists on numbers of tissue sections to examine.

Medroxyprogesterone acetate therapy in advanced breast cancer: the predictive value of androgen receptor expression.

PURPOSE: To determine the predictive value of androgen receptor (AR) levels in primary tumors of women who undergo medroxyprogesterone acetate (MPA) therapy for advanced breast cancer after relapse on tamoxifen adjuvant therapy. METHODS: Between 1984 and 1987 at Flinders Medical Centre, South Australia, 136 postmenopausal women received adjuvant tamoxifen therapy for lymph node-positive breast cancer. Estrogen receptor (ER), progesterone receptor (PgR), and AR levels, tumor size, and degree of axillary node involvement were determined at the time of diagnosis. The median follow-up period was 81 months; 89 women developed metastatic disease, 83 of whom subsequently received MPA (500 mg/d). The objective response rate ([RR] ie, complete response [CR] and partial response [PR]) and progression-free interval (PFI) were assessed in response to MPA therapy. Associations between RR, PFI, and primary tumor characteristics including ER, PgR, and AR levels were examined using the Mann-Whitney U test, Kaplan-Meier product-limit estimator, and Cox proportional hazards regression, as appropriate. RESULTS: Thirty-two of 83 patients (38.6%) responded to MPA. RR was significantly associated with the presence of AR (P < .001), but not with other primary tumor characteristics or duration of tamoxifen therapy. After initiation of MPA treatment, PFI increased with increasing concentration of AR in the primary tumor. CONCLUSION: Response to MPA after adjuvant tamoxifen treatment for lymph node-positive breast cancer was positively associated with AR level in the primary tumor. This finding suggests that MPA action in breast cancer may be mediated in part by the AR.

Treatment and survival from colorectal cancer: the experience of patients at South Australian teaching hospitals between 1980 and 2002.

AIMS: To evaluate trends in colorectal cancer survival and treatment at South Australian teaching hospitals and degree of adherence to treatment guidelines which recommend adjuvant chemotherapy for Dukes' C colon cancers and combined chemotherapy and radiotherapy for high-risk rectal cancers. MATERIALS AND METHODS: Trends in disease specific survival and primary treatment were analysed, and comparisons drawn between diagnostic epochs, using cancer registry data from South Australian teaching hospitals. Statistical methods included univariate and multivariable disease specific survival analyses. RESULTS: Five-year survival increased from 48% in 1980-1986 to 56% in 1995-2002. Largest gains were for stage C, where survivals were higher when chemotherapy was part of the primary treatment. By comparison, gains in 1-year survival were largest for stage D. Chemotherapy was provided for 4% of patients with colorectal cancers in 1980-1986, increasing to 32% in 1995-2002. Among stage C cases below 70 years at diagnosis, the proportion having chemotherapy increased to 83% in 1995-2002. The most common chemotherapy was fluorouracil (5FU) as a single agent in 1980-1986 and 5FU with leucovorin in 1995-2002. As expected, radiotherapy was used more frequently for rectal than colon cancers, and particularly for stage C. Among stage C rectal cases below 70 years, the proportion having radiotherapy increased from 10% in 1980-1986 to 57% in 1995-2002. Approximately 93% of colorectal cancers were treated surgically. Patients not treated surgically tended to be aged 80 years or more and to present with distant metastases. CONCLUSIONS: Trends in chemotherapy and radiotherapy accord with evidence-based recommendations. There have been reassuring gains in survivals after adjusting for stage, grade and other prognostic indicators. The data show survival gains and treatment patterns that individual hospitals can use as benchmarks when evaluating their own experience.

Detection by screening mammography is a powerful independent predictor of survival in women diagnosed with breast cancer.

Four hundred and sixteen invasive breast cancers, detected initially by mammography, were compared with 929 presenting symptomatically, all treated at a South Australian teaching hospital. Predictable differences included lower stages and grades, less vascular invasion and proliferative activity, and more hormone-receptor expression among the mammographically detected. Unpredicted differences included significantly higher survivals for mammographically detected cases throughout the 9 year follow-up period after adjusting for stage and the Nottingham Prognostic Index. In a multivariable analysis, differences in stage, grade, and hormone receptor expression accounted for only about half the survival advantage of mammographically detected tumours. Accounting for additional person and tumour characteristics had only a marginal effect on this result. This suggests that detection by mammography has independent favourable prognostic significance beyond that explained by conventional indicators. If confirmed, this finding would have important implications for the prognostic advice given to women and may merit further investigation into its underlying biological mechanisms.

An analysis of factors associated with interval as opposed to screen-detected breast cancers, including hormone therapy and mammographic density.

A comparison of 270 interval breast cancers in South Australian women aged 50 years and over with 628 age-matched screen-detected cases indicated that the former had more advanced stages (P<0.001), higher grades (P<0.001), and more frequently a history of past breast problems (P<0.027). After adjusting for these factors, and presence of a self-reported breast lump at the last screen, using conditional logistic regression, hormone replacement therapy (HRT) exposure in the 6 months prior to this screen had a raised relative odds (95% CL) of an interval cancer of 1.48 (1.02, 2.14). For 479 women where breast density was measured, high density showed an elevated relative odds of an interval cancer of 2.62 (1.71, 4.02). The relative odds of a high density was raised to 2.02 (1.33, 3.06) when the HRT history was positive. Screeners should be aware when there is a history of HRT or past breast problems, or a high breast density, that there is an increased probability of a subsequent interval cancer.

Tumour location and prognostic characteristics as determinants of survival of women with invasive breast cancer: South Australian hospital-based cancer registries, 1987-1998.

Survivals from breast cancer varied by location of lesion (P<0.001), with 10-year survivals of 61% applying for central (n=772), 73% for medial (n=350), and 72% for lateral (n=966) lesions. Univariate analyses of determinants of central locations indicated that the following were predictive: a more advanced TNM stage (P<0.001); a larger tumour diameter (P=0.002); a higher grade (P=0.032); a negative oestrogen receptor status (P=0.004); a negative progesterone receptor status (P=0.004); and histological type (P=0.011), with more of the lobular lesions being located centrally. Cox proportional hazards regression indicated that the relative risk (95% confidence limits) of case fatality for central, as opposed to other, lesions reduced from 1.46 (1.20, 1.78) to 1.16 (0.95, 1.41) when stage was added to the model, with no other factor having an additional conditioning effect. It is concluded that central lesions have worse outcomes, mostly due to their more advanced stages. Means of finding these tumours earlier should be investigated.

Characteristics of near-fatal asthma in childhood.

As part of the South Australian asthma mortality survey, we examined 30 cases of near-fatal asthma attacks in children under 15 years of age who were seen over a 3-year period from May 1988 to June 1991. Subjects presented with asthma and either respiratory arrest, PaCO2 above 50 mm Hg, and/or an altered state of consciousness or inability to speak on presentation at a metropolitan Adelaide teaching hospital. A standardized interview and questionnaire was completed with subjects/parents and medical practitioners. Data were reviewed by the assessment panel which made collective judgments based on predetermined criteria. Seventeen patients (57%) were male, 20% were less than 7 years of age, and the majority (53%) were aged between 12 and 15 years. The majority (83%) had severe asthma and only one case (3.3%) had mild asthma. Half of the subjects were waking every night due to asthma and 79% had significant exercise limitation. A quarter of the subjects had a previous ICU admission and 70% had a hospital admission in the last 12 months. Primary care was carried out by a general practitioner in 57% of cases, and 70% of subjects had a crisis plan. Only 46% of those older than 7 years of age had ever used a peak-flow meter. Eighty percent of subjects or their families had high denial scores, and in 73% of cases psychosocial factors were considered to be significant. Eighty percent of cases experienced acute progressive respiratory distress, and 63% of cases delayed seeking medical care.(ABSTRACT TRUNCATED AT 250 WORDS)

Tooth loss in South Australia.

A survey of approximately 8,300 subjects in the State of South Australia indicated that approximately 228,400 South Australians aged 15 years and over (26%) were edentulous and, of these, 95% wore full maxillary and mandibular dentures. The proportion of edentulous subjects increased with age and was lower in males, upper socioeconomic groups, immigrants and in the State capital.

Saliva-based colorimetric test as an index of gingival inflammation in epidemiologic studies.

There is a pressing need for a reliable, low-cost method of assessing the gingival and periodontal status of large population groups. Existing indexes, despite their value in dental public health, are still too subject to examiner variability for use by uncalibrated examiners. This study describes an evaluation of a quick, inexpensive, extraoral colorimetric test for gingival inflammation, based on a reaction between saliva and the test material. It could probably be applied by non-professional personnel. In this study, the test was applied to a population of elementary schoolchildren, dental hygiene students and faculty, and adult inmates of two correctional institutions. These populations were chosen on the assumption that they would exhibit varying intensities of gingival inflammation. Values obtained from the colorimetric test carried out by one researcher were compared with Gingival Index (GI) scores observed by a different examiner. Results suggest that the colorimetric test may be a valid, reliable means of detecting major differences in the prevalence of gingival inflammation in most adult populations, although having little, if any, useful application among children at the mixed dentition stage.

Assessing the effectiveness of dental health education in the South Australian School Dental Programme.

Approximately 25--30 per cent of operational time in the School Dental Programme is assigned to dental health education, representing a sizeable investment of public resources. If the full potential of dental health education is to be realized, the respective effectiveness of various dental health education activities need to be identified so that the more effective activities can be emphasized and developed further. As an essential prerequisite there is a need to refine the evaluation process by introducing: (1) improved dental indices; (2) improved methods of classifying and maintaining records of the dental health education activities undertaken; (3) better methods of quantifying dental care items and other social and environmental covariables; and (4) more sophisticated forms of multivariate analysis.

The effect of treatment provided by dentists and therapists in the South Australian school dental service. The second report.

A survey of over 2,000 second year high school students at 13 South Australian schools indicated that those who had received school dental care at primary school had fewer carious teeth and, in some respects, better oral hygiene habits. Whilst they were better informed on dental subjects than were control students, fewer had attended a private dentist since leaving primary school.

The treatment of first permanent molars in a school dental programme: implications for fissure sealants.

Analysis of data derived from the pattern of treatment for first permanent molars in New Zealand school children from fluoridated and non-fluoridated areas shows that occlusal surfaces became carious at a later age in the former and in such areas sealants could further reduce the need for occlusal restorations. Since occlusoproximal restorations are rare, retention of sealants for long periods is needed.

Fluoridation 1. Effects on children's caries rates and professionally defined requirements for dental care.

In 1977, after six years of fluoridation in South Australia, 337 six year-olds with continuous fluoride-drinking-water histories had DMFT values 53.2 per cent lower and df values 48.5 per cent lower than base-line values. For five to six year-olds presenting for follow-up care in the School Dental Service in 1977, continuous intake of fluoridated water evidently had reduced: (1) the number of teeth needing restorations by 40.0 per cent; (2) the total care items required by 32.6 per cent; (3) the total time required for care by 37.5 per cent; and (4) the fee-for-service value of care required by 34.3 per cent.

The sealing of fissures in a school dental programme.

An examination was made of 817 children, mean age 6.9 years. Of their first permanent molars 42.4 per cent were assessed as suitable for fissure sealant. Of these teeth 522 were sealed and compared with contra-lateral controls after one year. The retention rate of and the mean application time for the sealant are presented and discussed.

The dental health status of children not included by parents in the South Australian School Dental Programme. A pilot study.

About 90 per cent of children have received school dental care at South Australian schools where this care has been available. However, following recent extension of the dental programme to metropolitan schools without clinics located in their grounds, lower participation rates of about 74 per cent have emerged. A pilot study of 161 children not included in the school dental programme at 13 of these metropolitan schools without clinics was conducted to evaluate their dental health status and determine why they were not enrolled for school dental care.

The effect of a pilot dental health education programme on high school students.

A dental health education programme for fourth and fifth year high school students reduced the levels of debris and periodontal disease significantly. Although the use of recommended toothbrushes and fluoride paste was increased the demand for professional care was greater in the control group.

A systematic review of surgical biopsy for LCIS found at core needle biopsy - do we have the answer yet?

BACKGROUND: The natural history of lobular carcinoma in-situ (LCIS) suggests that women are at increased risk of subsequent invasive breast cancer. Questions of effective management for women with this lesion have led to the need for evidence-based guidance and, in particular, guidance regarding management after LCIS is found at core needle biopsy (CNB). METHODS: A systematic review was conducted to determine the most appropriate management for women with LCIS found at CNB. A comprehensive search of the scientific literature was conducted to identify the literature pertaining to this population. Critical appraisal of the literature, data extraction and a narrative synthesis of the results were conducted. The outcome of interest was upgrade of diagnosis to invasive breast cancer or ductal carcinoma in-situ (DCIS). RESULTS: Sparse data, with limited generalisability and considerable uncertainty, are available for women with LCIS at CNB. Nine studies were identified that met pre-specified inclusion criteria. The reported estimates of upgrade of diagnosis from LCIS to invasive breast cancer or DCIS ranged from 2% to 25%. The body of evidence was limited by its retrospective nature, risk of selection bias and poor generalisability to all women with LCIS at CNB. Further, higher quality research is required to determine the best approach for women with LCIS at CNB with any certainty.