Health-related quality of life in rural cancer survivors compared with their urban counterparts: a systematic review.

PURPOSE: We conducted a systematic review to describe health-related quality of life (HRQOL) in rural cancer survivors (RCS), and compare HRQOL between RCS and urban cancer survivors (UCS). METHOD: We searched Medline, Embase, CINAHL Plus, and PsycINFO for studies with HRQOL in adult cancer survivors living in rural, regional, remote, and urban areas, who had completed definitive primary cancer treatment, without evidence of residual disease. Where available, we used normative and clinically important values to ascribe meaning to HRQOL data. FINDINGS: Fifteen studies (16 papers) were included. Most were from the US (n = 8) and reported on breast cancer survivors (n = 9). Six HRQOL instruments, collecting data across 16 domains, were used. Three instruments were specific to the survivorship phase. Normative and clinical data were available for 12 studies. Compared with normative populations, RCS had clinically worse physical HRQOL (6/12 studies), better social/family (5/7), and functional (3/6) HRQOL, and there were no differences in emotional or/mental HRQOL (9/12). In six studies with rural-urban comparator groups and normative and clinically important data, RCS and UCS had clinically worse physical (3/6 and 2/6, respectively) and better social/family (3/4 and 2/4 studies, respectively) HRQOL than normative populations. Functional HRQOL was better in RCS (2/4 studies) than UCS and normative populations. In 3/6 studies, there were no clinical differences in emotional or/mental HRQOL between RCS, UCS, and normative populations. CONCLUSION: Overall, HRQOL is not clearly better or worse in RCS than UCS. Future research should include different tumor types, rural residents, and survivorship-specific HRQOL instruments.

Clinical management of Australian adolescents and young adults with acute lymphoblastic and myeloid leukemias: A national population-based study.

BACKGROUND: While several studies have examined the treatment of adolescents and young adults (AYAs) with acute lymphoblastic leukemia (ALL), studies of acute myeloid leukemia (AML) are rare. Using national data for Australia, we describe (i) the number and type of treatment centers caring for AYAs, (ii) induction/first-line treatments, and (iii) survival outcomes. PROCEDURE: National population-based study assessing treatment of 15- to 24-year-olds diagnosed with ALL or AML between 2007 and 2012. Treatment details were abstracted from hospital medical records. Treatment centers were classified as pediatric or adult (adult AYA-focused or other adult; and by AYA volume [high/low]). Cox proportional hazard regression analyses examined associations between treatment and overall, event-free, and relapse-free survival outcomes. RESULTS: Forty-seven hospitals delivered induction therapy to 351 patients (181 ALL and 170 AML), with 74 (21%) treated at pediatric centers; 70% of hospitals treated less than two AYA leukemia patients per year. Regardless of treatment center, 82% of ALL patients were on pediatric protocols. For AML, pediatric protocols were not used in adult centers, with adult centers using a non-COG 7+3-type induction protocol (51%, where COG is Cooperative Oncology Group) or an ICE-type protocol (39%, where ICE is idarubicin, cytarabine, etoposide). Exploratory analyses suggested that for both ALL and AML, AYAs selected for adult protocols have worse overall, event-free, and relapse-free survival outcomes. CONCLUSIONS: Pediatric protocols were commonly used for ALL patients regardless of where they are treated, indicating rapid assimilation of recent evidence by Australian hematologists. For AML, pediatric protocols were only used at pediatric centers. Further investigation is warranted to determine the optimal treatment approach for AYA AML patients.

Inconsistencies and time delays in site-specific research approvals hinder collaborative clinical research in Australia.

BACKGROUND/AIM: The aim of this study was to describe the time and documentation needed to gain ethics and governance approvals in Australian states with and without a centralised ethical review system. METHODS: This is a prospective descriptive study undertaken between February 2012 and March 2015. Paediatric and adult hospitals (n = 67) in Australian states were approached to allow the review of their medical records. Participants included 15- to 24-year-olds diagnosed with cancer between 2008 and 2012. The main outcomes measures were time (weeks) to approval for ethics and governance and the number and type of documents submitted. RESULTS: Centralised ethics approval processes were used in five states, with approval taking between 2 and 18 weeks. One state did not use a centralised process, with ethics approval taking a median of 4.5 weeks (range: 0-15) per site. In four states using a centralised ethics process, 33 governance applications were submitted, with 20 requiring a site clinician listed as an investigator. Governance applications required the submission of 11 documents on average, including a Site-Specific Assessment form. Thirty-two governance applications required original signatures from a median of 3.5 (range: 1-10) non-research persons, which took a median of 5 weeks (range: 0-15) to obtain. Governance approval took a median of 6 weeks (range: 1-45). Twelve research study agreements were needed, each taking a median of 7.5 weeks (range: 1-20) to finalise. CONCLUSION: The benefits of centralised ethics review systems have not been realised due to duplicative, inflexible governance processes. A system that allowed the recognition of prior ethical approval and low-risk applications was more efficient than a central ethics and site-specific governance process.

What models of peer support do people with colorectal cancer prefer?

While colorectal cancer is the most common cancer affecting both men and women in Australia, disease-specific peer support services are lacking. This study examined the acceptability and preferred models of peer support among people with colorectal cancer. First, a mixed-method study examined enablers and barriers to peer support participation and model preferences. Participants were recruited from metropolitan and regional areas of Victoria. Fifty-three participants completed a questionnaire and four focus groups and 10 telephone interviews were conducted (n = 34). Participants demonstrated enthusiasm for peer support. Feeling unwell and worry about accessing toilet facilities were main barriers, while accessing information about treatment side effects and making treatment decisions were main positive features. Second, a pilot study determined the response to a face-to-face group and one-on-one telephone programme, the preferred models from study 1. In total, 34 support recipients recruited through clinicians, participated. Half elected to participate in the telephone programme and half in the group programme. Support recipients completed surveys before and after the programmes. Both models were acceptable to participants with high satisfaction rates reported (94-100%) and findings suggested that the two models catered to different peer support needs. Timing of referral and clinician promotion contributed to participation.

Does smoking among friends explain apparent genetic effects on current smoking in adolescence and young adulthood?

We used data from a prospective cohort study of twins to investigate the influence of unmeasured genetic and measured and unmeasured environmental factors on the smoking behaviour of adolescents and young adults. Twins were surveyed in 1988 (aged 11-18 years), 1991, 1996 and 2004 with data from 1409, 1121, 732 and 758 pairs analysed from each survey wave, respectively. Questionnaires assessed the smoking behaviour of twins and the perceived smoking behaviour of friends and parents. Using a novel logistic regression analysis, we simultaneously modelled individual risk and excess concordance for current smoking as a function of zygosity, survey wave, parental smoking and peer smoking. Being concordant for having peers who smoked was a predictor of concordance for current smoking (P<0.001). After adjusting for peer smoking, monozygotic (MZ) pairs were no more alike than dizygotic pairs for current smoking at waves 2, 3 and 4. Genetic explanations are not needed to explain the greater concordance for current smoking among adult MZ pairs. However, if they are invoked, the role of genes may be due to indirect effects acting through the social environment. Smoking prevention efforts may benefit more by targeting social factors than attempting to identify genetic factors associated with smoking.

How effective are tobacco industry bar and club marketing efforts in reaching young adults?

OBJECTIVE: Recently, the tobacco industry has focused marketing efforts on young adults through bar and club promotions, such as advertising and distribution of free cigarettes in these settings. This study estimates the fraction of the California young adult population that might be exposed and potentially influenced by these efforts. DESIGN AND PARTICIPANTS: Data were from 9364 young adult (18-29 years) respondents to the cross sectional population based 2002 California Tobacco Survey. As background, we analysed social smoking (only smoke with other smokers), and enjoyment of smoking while drinking. Our main focus was on bar and club attendance, what was observed in bars and clubs, and how this might differ according to respondents' risk for future smoking. RESULTS: Social smokers comprised 30.0 (2.2)% of all current smokers, including experimenters. Nearly three quarters (74.5 (2.3)%) of current smokers/experimenters said they enjoyed smoking while drinking. About one third (33.8 (1.2)%) of all young adults said they attended bars and clubs at least sometimes; attendance was significantly higher among smokers and those at risk for future smoking. Close to 60% (57.9 (2.2)%) of bar and club attenders reported seeing cigarette advertising and promotions in these settings. Again, smokers and those at risk were more likely to report seeing such advertising and promotions in these settings. CONCLUSIONS: About 20% of all young adults and about 30% of those at risk for future smoking (including current smokers) were exposed to tobacco advertising and promotions in bars and clubs. These California results may be conservative, but nonetheless indicate that the group potentially influenced is sizable.

Prediction of alcohol-related harm from controlled drinking strategies and alcohol consumption trajectories.

AIMS: To establish predictors of age 21 alcohol-related harm from prior drinking patterns, current levels of alcohol consumption and use of controlled drinking strategies. PARTICIPANTS: One thousand, five hundred and ninety-six students recruited from an initial sample of 3300 during their final year of high school in 1993. DESIGN: Longitudinal follow-up across five waves of data collection. SETTING: Post high school in Victoria, Australia. MEASUREMENTS: Self-administered surveys examining a range of health behaviours, including alcohol consumption patterns and related behaviour. FINDINGS: Drinking behaviours at age 21 were found to be strongly predicted by drinking trajectories established through the transition from high school. Multivariate regression analysis revealed that alcohol-related harms at age 21 were reduced where current levels of alcohol use fell within limits recommended in Australian national guidelines. After controlling for this effect it was found that the range of strategies employed by participants to control alcohol use maintained a small protective influence. Post-high-school drinking trajectories continued to demonstrate a significant effect after controlling for current behaviours. FINDINGS: revealed that over one quarter of males and females drank alcohol, but on a less-than-weekly basis. This pattern of alcohol use demonstrated considerable stability through the post-school transition and was associated with a low level of subsequent harm at age 21. CONCLUSIONS: Future research should investigate whether encouraging more Australian adolescents to drink alcohol on a less-than-weekly basis may be a practical intervention target for reducing alcohol-related harms.

Alcohol use among Australian secondary students in 1993.

The prevalence of alcohol consumption among Australian secondary students in 1993 was estimated from a survey of 22 696 students aged between 12 and 17 years. A random, representative sample of schools from all education systems (government, Catholic and independent) was selected and a sample of 80 students from each school was randomly selected from predetermined year levels. Students completed an anonymous, self-administered survey on their drinking behaviours. Results showed that drinking was common, with 46% of female and 50% of male 17-year-olds having drunk on at least one of the 7 days prior to the survey (defined as current drinkers). Among 12-17-year-olds who were current drinkers, 27% of males had five or more alcoholic drinks on at least one drinking ("heavy drinking") while 43% of girls had had three or more drinks ("heavy drinking"). Among current drinkers aged 12-15 years, 10% of boys and 12% of girls had "binged" (for boys drinking eight or more drinks in one session, for girls having six or more drinks at one session) while among current drinkers aged 16 and 17 years the corresponding proportions were 33% of boys and 30% of girls. After controlling for age, sex, school type and state, the proportion of 12-15-year-olds who were current drinkers rose from 24% to 26% between 1990 and 1993. Among 16 and 17-year-olds, the proportion of current drinkers in 1993 (47%) was the same as that found in 1990, although there were more heavy drinkers and binge drinkers in 1993 than in 1990.

Barriers to cervical screening in older women.

OBJECTIVE: To explore the reasons why some older women do not have regular Papanicolaou smear tests. SETTING: The Ballarat region of Victoria. DESIGN AND METHOD: Cross-sectional survey administered by telephone interview. SAMPLE: Three hundred and forty-seven women aged 40 to 70. RESULTS: 1. 41% of women had not had a Papanicolaou smear test within the preceding 2 years. 2. Women who agreed with the statement that healthy women do not need to have Papanicolaou tests were six times more likely to be overdue for a Papanicolaou test than women who did not agree. 3. Being over 60 significantly increased the likelihood that a woman would be overdue for a Papanicolaou test, compared with younger women. 4. Women who thought that the test is only needed at intervals of 3 years or more were over six times more likely to be overdue than women who believed the interval to be 2 years or less. 5. Women who perceived themselves as being too embarrassed were nearly seven times more likely to be overdue than women who claimed no embarrassment. 6. Women who saw themselves as being too busy to have the test were three times more likely to be overdue than women who did not see themselves this way. 7. Women with a spouse were less likely to be overdue than other women. 8. Women who knew to start having Papanicolaou tests when they were sexually active were less likely to be overdue than women who did not know this. CONCLUSION: Many of these barriers can be overcome by the clinician in routine practice.

Australian adult smoking prevalence in 1992.

To estimate the prevalence of smoking among Australian adults in 1992, 6046 adults aged 16 years and over (3063 men and 2983 women) were interviewed. A large market-research firm interviewed the sample, face-to-face in their homes during weekends. Overall, 28.2 per cent of men and 23.8 per cent of women were current smokers; 32.3 per cent of men and 21.9 per cent of women were past smokers. On average, male smokers consumed 22.1 factor-made cigarettes a day and female smokers consumed 19.1 cigarettes a day. The daily tar intake was 179 mg for male smokers and 131 mg for women. The most popular packet size was 25 (40 per cent of smokers) followed by the packet of 50 (17 per cent). Occupational and education status were inversely related to smoking prevalence. Men and women with less education and men in low-status occupations were more likely to use cigarettes from the large packet sizes. Comparison with earlier data suggests that smoking prevalence is still declining, with a significant recent drop in female but not male smoking prevalence. While in 1992, the prevalence of smoking among women was less than that for men, projected estimates suggest that by the year 2001 more women than men will smoke.

Measures of tobacco smoking in Australia 1974-1986 by means of a standard method.

Trends in smoking among Australian adults as based upon surveys with a standard method in 1974, 1976, 1980, 1983 and 1986 are presented. The percentage of male cigarette smokers fell from 42.2% in 1974 to 31.9% in 1986 and the percentage of female smokers was 29.5% in 1974 and 28.8% in 1986. Over the period of observation, the percentage of past smokers of both sexes climbed steadily and, in 1986, reached 28.1% of men and 16.8% of women.

Smoking behaviours of Australian adults in 1995: trends and concerns.

OBJECTIVES: To estimate the prevalence of smoking among Australian men and women in 1995 and to examine trends in smoking prevalence in Australia over the past 10 years. DESIGN: A representative sample of adults participated in face-to-face interviews conducted by a large market research company. PARTICIPANTS: 2819 men and 2880 women over the age of 16. MAIN OUTCOME MEASURE: Self-reported smoking behaviours assessed by standard questions. RESULTS: Overall, 27.1% of men and 23.2% of women were smokers of tobacco (factory-made cigarettes, pipes, cigars or roll-your-own cigarettes). This difference in smoking prevalence of men and women was significant. More men (32.1%) than women (21.7%) were past smokers and more women (53.4%) than men (39.3%) had never been regular smokers. On average, male smokers smoked about 20 factory-made cigarettes a day, while women smoked about 18. Occupation and education levels were inversely related to smoking prevalence. Comparisons with earlier data suggest that the decline in smoking prevalence seen in previous surveys has ceased. However, the number of cigarettes consumed daily decreased between 1992 and 1995. In the period between 1983 and 1989, when per capita expenditure on adult antismoking campaigns rose, smoking prevalence declined, but levelled off thereafter in a period when expenditure on campaigns fell. CONCLUSION: Failure to find a continuing decline in prevalence of smoking among the Australian population is of great concern and indicates the importance of continuing and extending antismoking programs.

Australian patterns of tobacco smoking in 1989.

OBJECTIVE: To estimate the national prevalence of smoking. DESIGN: A total of 4820 adults aged 16 years and over (2364 men, 2456 women) were surveyed throughout Australia in 1989 by a large market research company. SETTING: Interviews were conducted in the participants' homes. RESULTS: Overall, 30.2% of men and 27.0% of women were current smokers; 29.8% of men and 19.3% of women were past smokers. The mean daily consumption of factory-made cigarettes among male smokers was 22 and among female smokers 18.9. Taking into account the published tar content of the brand smoked, it was estimated that the average daily exposure to tobacco tar for men was 204 mg and for women 157 mg. Occupational and educational status were inversely related to the prevalence of smoking. The most popular packet size was 25 (preferred by 48% of smokers) and those in lower occupational and educational categories were more likely to purchase cigarettes in large packet sizes. CONCLUSIONS: Comparison with an earlier series of studies commenced in 1974 showed that the national prevalence of smoking among adults has continued to fall, particularly among men.

Tobacco and alcohol use among Australian secondary schoolchildren in 1987.

A survey of 19 166 secondary schoolchildren aged 12-17 years in five Australian states, the Australian Capital Territory and the Northern Territory was undertaken in 1987 to determine the prevalence of tobacco and alcohol use. Current smoking (that is, smoking at least one cigarette in the last week) rose with age to 27% in boys who were aged 16 years and to 30% in girls who were aged 16 years. The prevalence of current drinking (that is, consuming one alcoholic drink in the last week) rose with age to 55% in boys who were aged 16 years and to 50% in girls who were aged 17 years. Compared with an identical survey in 1984, the prevalence of smoking among 12- to 17-year-old schoolchildren had fallen significantly. The prevalence of drinking alcohol among 12- to 15-year-old schoolchildren also had fallen significantly, but not to the same extent as that of smoking; no significant reduction was found in the drinking of alcohol among 16- to 17-year-old schoolchildren. These trends are encouraging, but a need remains for all states to enact tobacco-control legislation, including the prohibition of tobacco advertising.

Tobacco and alcohol use among Australian secondary school students in 1990.

OBJECTIVE: To obtain up-to-date prevalence estimates of tobacco smoking and alcohol drinking among Australian secondary students, and to compare these estimates with those obtained from similar studies conducted in 1984 and 1987. DESIGN: Data were collected from 24,892 secondary students aged 12 to 17 years from all Australian States and the Northern Territory. A stratified two-stage sample design was used. First, a random sample of schools was selected and second, for each school a sample of 80 students was randomly selected from predetermined year levels. A total of 351 schools participated in the survey. Students completed an anonymous, self-administered questionnaire on their smoking and drinking behaviours. RESULTS: The prevalence of current smoking (defined as having smoked at least one cigarette in the week preceding the survey) was found to increase with age to reach a peak of 25% among 16-year-old boys and 29% among girls aged 15 years. From the age of 13, smoking was more prevalent among girls than boys. Among current smokers, boys were heavier smokers than were girls. Unlike smoking, drinking was slightly more prevalent among boys than girls; boys were heavier drinkers. The proportion consuming at least one alcoholic drink in the week before the survey rose with age to a peak of 51% of boys and 46% of girls aged 17 years. Comparisons with data obtained from a similar survey conducted in 1987 showed that there had been a decrease in the proportion of 12 to 15 year olds smoking. The prevalence of drinking among both 12 to 15 year olds and 16 to 17 year olds was significantly lower in 1990 than 1987. CONCLUSIONS: While the continuing downward trends in smoking and drinking among younger students is encouraging, the results show that there are still large numbers of students smoking and drinking.

Knowledge, attitudes and self-care practices related to sun protection among secondary students in Australia.

The aim of this research was to ascertain changes in sun-related knowledge, attitudes and self-care practices among Australian secondary school students between 1993 and 1996. Two cross-sectional surveys of sun-related attitudes, beliefs and behavior of young people aged 12-17 years of age, were conducted in 1993 and 1996. Over 80% of adolescents at both time periods knew about the issues related to skin cancer prevention, frequency of burning and burning on cloudy days. Adolescent attitudes had shifted positively in the areas of staying inside in 1996 [relative risk (RR): 1.13; 95% confidence interval (CI): 1.09-1.17] and staying under shade in 1996 (RR: 1.16; 95% CI: 1.13-1.18). Desire for a moderate or dark tan was lower in 1996 (45%) than in 1993 (50%). Respondents reported that they were less likely to wear brief clothing to get a suntan in 1996 (RR: 0.81; 95% CI: 0.78-0.84) and were significantly more likely to stay in the shade in 1996 (RR: 1.19; 95% CI: 1.16-1.23). We conclude that there has been a shift in attitudes towards use of shade and avoidance of unnecessary exposure, and away from use of sunscreens and sunglasses. The results suggest that adolescents may be more ready to accept structural changes that move desired activities out of the sun.

Alcohol use, smoking habits and the Adult Eysenck Personality Questionnaire in adolescent Australian twins [corrected].

In 1988, questionnaires were received from 1,400 twin pairs (17% MZM, 23% MZF, 17% DZM, 19% DZF, 24% DZO) aged 11 to 18, registered with the Australian NHMRC Twin Registry. Twins reported independently on themselves and on the perceived behaviour of their parents, siblings and friends. For smoking and for drinking in the previous month, the prevalence was modelled as a logistic function of age, sex, perceived smoking or drinking behaviour of family and friends, and the Adult Eysenck Personality Questionnaire (AEPQ) scales. Strengths of association were: family behaviour, odds ratio (OR) < or = 2; Extraversion and Psychoticism, interquartile OR approximately 1.6; behaviour of friend, OR approximately 3 to 6. Twin associations were represented by odds ratios. For smoking they were 16 in MZ and 7 in DZ same-sex pairs, and 3 in DZO pairs. Although the former is consistent with genetic factors determining adolescent smoking behaviour, the reduced association in DZO pairs and strong association with smoking by friends argue to the contrary. For drinking, twin odds ratios were 11 in MZM, MZF and DZF pairs, and 4 in DZM and DZO pairs, consistent with genetic factors determining alcohol use in male but not female, adolescents. Twin odds ratios were not influenced by adjustment for the AEPQ scales; this does not support the hypothesis that genetic factors which determine personality also determine smoking or drinking behaviour during adolescence [corrected].

Changes in the investigation and management of primary operable breast cancer in Victoria.

OBJECTIVES: To investigate the surgical practice and adjuvant therapies used in the treatment of primary operable breast cancer in Victoria in 1990 and compare them with results of a similar study in 1986. DESIGN: All 856 cases of primary operable breast cancer registered by the Victorian Cancer Registry between 1 April and 30 September 1990 were identified. Each patient's surgeon was sent a standard questionnaire covering diagnosis, investigations, operative procedures, adjuvant therapies and reasons for certain management choices. Data were collected on 89% of the patients from 176 participating surgeons. RESULTS: Most patients (82%) were referred to surgeons by general practitioners. Mammographic screening detected 14% of the cancers. The proportion of women receiving breast-conserving operations rose from 22% in 1986 to 42% in 1990. Surgeons operating on more than 20 breast cancers per annum were most likely to perform breast-conserving operations. The most common reasons given for non-conservative operations were the size of the tumour (37%), its central location (25%) and/or patient concern about the risk of recurrence if the breast was to be conserved (22%). Among these patients, reconstruction was done at the time of primary treatment in 13%, subsequently in 2%, and was planned by another 5%. Of all patients, 33% were referred to a radiation oncologist and 24% actually received radiotherapy (similar to 1986). Medical oncologists saw 33% of the patients and 20% of all patients received chemotherapy (similar to 1986), which was given by a medical oncologist in 83% of the cases. Use of endocrine therapy increased from 20% in 1986 to 40% in 1990. CONCLUSIONS: There has been a strong trend towards more conservative breast surgery in Victoria, with surgeons who are most active in breast cancer surgery most likely to perform breast-conserving operations. Apart from a significant increase in the use of endocrine therapy, use of adjuvant therapies was unchanged from 1986.

Distribution and metabolism of vincristine in mice, rats, dogs, and monkeys.

An extraction procedure that allows measurement of [3H]vincristine and its metabolites in biologic fluids and tissues has been developed and used to determine the distribution and metabolism of vincristine in mice, rats, dogs, and monkeys. Very little tritium exchange occurred during the experiments. In mice and rats injected ip with [3H]vincristine, the peak serum levels of drug were reached at 15 minutes. For both mice and rats, the concentration of vincristine metabolites rose in the serum for 30 minutes, then remained high through 3 hours. For dogs and monkeys given an iv dose of [3H]vincristine, the initial serum levels fell rapidly, with half-lives for the first phase of 6 and 10 minutes respectively. The half-life for both of the second phases was 190 minutes. For both species, the serum level of metabolites fell for 2 hours, then remained relatively constant. These results were not appreciably altered when the animals were injected simultaneously with prednisone. Compared to serum levels in mice, rats, dogs, and monkeys, there was a marked accumulation of [3H]vincristine in all tissues examined, except the brain. The pancreas, spleen, kidneys, lungs, and liver of dogs and monkeys contained the largest amounts. The tissue distribution was not greatly different in dogs and monkeys injected simultaneously with prednisone. Urinary excretion of intact vincristine and its metabolites was observed for all four species. Both vincristine and its metabolites appeared in the bile of dogs and monkeys.