Implementing an evidence-based guideline to decrease opioids after cardiac surgery.

BACKGROUND: Deaths related to overdoses continue growing in the United States. The overprescription of opioids after surgical procedures may contribute to this problem. LOCAL PROBLEM: There is inconsistency in the prescription of opioids in cardiovascular surgery patients. Recommendations regarding the reduction of opioids at discharge are not fully implemented. METHODS: This is a single-center, pre-post quality improvement project in adult patients after elective cardiac surgery through sternotomy. INTERVENTIONS: Changes in guidelines, modification of order sets, creation of dashboards, and education to the providers to increase the prescription of acetaminophen around the clock on the step-down unit and at discharge, decrease the number of opioid tablets to 25 or less at discharge and decrease the prescription of opioids to 25 or less morphine milligram equivalents (MME) at discharge. RESULTS: The preintervention group included 67 consecutive patients who underwent cardiac surgery from November to December 2021. The postintervention group had 67 patients during the same period in 2022. Acetaminophen prescription on the step-down unit increased from 9% to 96% ( p < .001). The proportion of patients discharged with 25 or less opioid tablets increased from 18% to 90% ( p < .001) and with 25 or less MME from 30% to 55% ( p < .01). Acetaminophen prescription at discharge increased from 10% to 48% ( p < .001). CONCLUSIONS: Our intervention increased the use of acetaminophen and decreased the overprescription of opioids in cardiac surgery patients at discharge. Further research is necessary to continue improving pain management to reduce the number of opioids prescribed at discharge.

Improving healthcare quality for transgender patients in the perioperative setting: The patient's perspective.

Transgender individuals reported higher rates of discrimination and barriers to care within healthcare settings than their cisgender counterparts. There is a paucity of literature concerning the barriers experienced within perioperative healthcare settings. Participants completed a sociodemographic questionnaire and a 7-item Likert-type scale survey: the Everyday Discrimination Scale Adapted for Medical Settings. Overall, 57% of trans-individuals who underwent gender-affirming surgery reported perceptions of discrimination when interacting with healthcare providers within the perioperative setting according to responses from the Discrimination in Medical Settings Survey. There was an overall difference in the summary scores between participants based on gender transition. These findings highlight an opportunity to address barriers to care related to discrimination and negative patient-provider interactions. These findings have implications for the development and integration of patient-informed, evidence-based, trans-specific, educational and cultural competency trainings to enhance the healthcare professional's knowledge, attitudes, comfort and ability to care for the transgender population.Key phrases: Transgender individuals reported higher rates of discrimination and barriers to care; enhancing the healthcare professional's knowledge, attitudes, comfort and ability to care for the transgender population; opportunities to address barriers to care related to discrimination and negative patient-provider interactions; individuals who transitioned from male-to-female (MTF) had higher scores related to perceptions of discrimination during interactions with healthcare providers.

Pathways to diagnosis of non-small cell lung cancer: a descriptive cohort study.

Little has been published on the diagnostic and referral pathway for lung cancer in Australia. This study set out to quantify general practitioner (GP) and lung specialist attendance and diagnostic imaging in the lead-up to a diagnosis of non-small cell lung cancer (NSCLC) and identify common pathways to diagnosis in New South Wales (NSW), Australia. We used linked health data for participants of the 45 and Up Study (a NSW population-based cohort study) diagnosed with NSCLC between 2006 and 2012. Our main outcome measures were GP and specialist attendances, X-rays and computed tomography (CT) scans of the chest and lung cancer-related hospital admissions. Among our study cohort (N = 894), 60% (n = 536) had ≥4 GP attendances in the 3 months prior to diagnosis of NSCLC, 56% (n = 505) had GP-ordered imaging (chest X-ray or CT scan), 39% (N = 349) attended a respiratory physician and 11% (N = 102) attended a cardiothoracic surgeon. The two most common pathways to diagnosis, accounting for one in three people, included GP and lung specialist (respiratory physician or cardiothoracic surgeon) involvement. Overall, 25% of people (n = 223) had an emergency hospital admission. For 14% of people (N = 129), an emergency hospital admission was the only event identified on the pathway to diagnosis. We found little effect of remoteness of residence on access to services. This study identified a substantial proportion of people with NSCLC being diagnosed in an emergency setting. Further research is needed to establish whether there were barriers to the timely diagnosis of these cases.

Self-selection in a population-based cohort study: impact on health service use and survival for bowel and lung cancer assessed using data linkage.

BACKGROUND: In contrast to aetiological associations, there is little empirical evidence for generalising health service use associations from cohort studies. We compared the health service use of cohort study participants diagnosed with bowel or lung cancer to the source population of people diagnosed with these cancers in New South Wales (NSW), Australia to assess the representativeness of health service use of the cohort study participants. METHODS: Population-based cancer registry data for NSW residents aged ≥45 years at diagnosis of bowel or lung cancer were linked to the 45 and Up Study, a NSW population-based cohort study (N~ 267,000). We measured hospitalisation, emergency department (ED) attendance and all-cause survival, and risk factor associations with these outcomes using administrative data for cohort study participants and the source population. We assessed bias in prevalence and risk factor associations using ratios of relative frequency (RRF) and relative odds ratios (ROR), respectively. RESULTS: People from major cities, non-English speaking countries and with comorbidites were under-represented among cohort study participants diagnosed with bowel (n = 1837) or lung (n = 969) cancer by 20-50%. Cohort study participants had similar hospitalisation and ED attendance compared with the source population. One-year survival after major surgical resection was similar, but cohort study participants had up to 25% higher post-diagnosis survival (lung cancer 3-year survival: RRF = 1.24, 95% confidence interval 1.12,1.37). Except for area-based socioeconomic position, risk factors associations with health service use measures and survival appeared relatively unbiased. CONCLUSIONS: Absolute measures of health service use and risk factor associations in a non-representative sample showed little evidence of bias. Non-comparability of risk factor measures of cohort study participants and non-participants, such as area-based socioeconomic position, may bias estimates of risk factor associations. Primary and outpatient care outcomes may be more vulnerable to bias.

Investigation of the international comparability of population-based routine hospital data set derived comorbidity scores for patients with lung cancer.

INTRODUCTION: The International Cancer Benchmarking Partnership (ICBP) identified significant international differences in lung cancer survival. Differing levels of comorbid disease across ICBP countries has been suggested as a potential explanation of this variation but, to date, no studies have quantified its impact. This study investigated whether comparable, robust comorbidity scores can be derived from the different routine population-based cancer data sets available in the ICBP jurisdictions and, if so, use them to quantify international variation in comorbidity and determine its influence on outcome. METHODS: Linked population-based lung cancer registry and hospital discharge data sets were acquired from nine ICBP jurisdictions in Australia, Canada, Norway and the UK providing a study population of 233 981 individuals. For each person in this cohort Charlson, Elixhauser and inpatient bed day Comorbidity Scores were derived relating to the 4-36 months prior to their lung cancer diagnosis. The scores were then compared to assess their validity and feasibility of use in international survival comparisons. RESULTS: It was feasible to generate the three comorbidity scores for each jurisdiction, which were found to have good content, face and concurrent validity. Predictive validity was limited and there was evidence that the reliability was questionable. CONCLUSION: The results presented here indicate that interjurisdictional comparability of recorded comorbidity was limited due to probable differences in coding and hospital admission practices in each area. Before the contribution of comorbidity on international differences in cancer survival can be investigated an internationally harmonised comorbidity index is required.

Cancer survival disparities worsening by socio-economic disadvantage over the last 3 decades in new South Wales, Australia.

BACKGROUND: Public concerns are commonly expressed about widening health gaps. This cohort study examines variations and trends in cancer survival by socio-economic disadvantage, geographical remoteness and country of birth in an Australian population over a 30-year period. METHODS: Data for cases diagnosed in New South Wales (NSW) in 1980-2008 (n = 651,245) were extracted from the population-based NSW Cancer Registry. Competing risk regression models, using the Fine & Gray method, were used for comparative analyses to estimate sub-hazard ratios (SHR) with 95% confidence intervals (CI) among people diagnosed with cancer. RESULTS: Increased risk of cancer death was associated with living in the most socio-economically disadvantaged areas compared with the least disadvantaged areas (SHR 1.15, 95% CI 1.13-1.17), and in outer regional/remote areas compared with major cities (SHR 1.05, 95% CI 1.03-1.06). People born outside Australia had a similar or lower risk of cancer death than Australian-born (SHR 0.99, 95% CI 0.98-1.01 and SHR 0.91, 95% CI 0.90-0.92 for people born in other English and non-English speaking countries, respectively). An increasing comparative risk of cancer death was observed over time when comparing the most with the least socio-economically disadvantaged areas (SHR 1.07, 95% CI 1.04-1.10 for 1980-1989; SHR 1.14, 95% CI 1.12-1.17 for 1990-1999; and SHR 1.24, 95% CI 1.21-1.27 for 2000-2008; p < 0.001 for interaction between disadvantage quintile and year of diagnosis). CONCLUSIONS: There is a widening gap in comparative risk of cancer death by level of socio-economic disadvantage that warrants a policy response and further examination of reasons behind these disparities.

After accounting for competing causes of death and more advanced stage, do Aboriginal and Torres Strait Islander peoples with cancer still have worse survival? A population-based cohort study in New South Wales.

BACKGROUND: Aboriginal and Torres Strait Islander peoples in Australia have been found to have poorer cancer survival than non-Aboriginal people. However, use of conventional relative survival analyses is limited due to a lack of life tables. This cohort study examined whether poorer survival persist after accounting for competing risks of death from other causes and disparities in cancer stage at diagnosis, for all cancers collectively and by cancer site. METHODS: People diagnosed in 2000-2008 were extracted from the population-based New South Wales Cancer Registry. Aboriginal status was multiply imputed for people with missing information (12.9%). Logistic regression models were used to compute odds ratios (ORs) with 95% confidence intervals (CIs) for 'advanced stage' at diagnosis (separately for distant and distant/regional stage). Survival was examined using competing risk regression to compute subhazard ratios (SHRs) with 95%CIs. RESULTS: Of the 301,356 cases, 2517 (0.84%) identified as Aboriginal (0.94% after imputation). After adjusting for age, sex, year of diagnosis, socio-economic status, remoteness, and cancer site Aboriginal peoples were more likely to be diagnosed with distant (OR 1.30, 95%CI 1.17-1.44) or distant/regional stage (OR 1.29, 95%CI 1.18-1.40) for all cancers collectively. This applied to cancers of the female breast, uterus, prostate, kidney, others (those not included in other categories) and cervix (when analyses were restricted to cases with known stages/known Aboriginal status). Aboriginal peoples had a higher hazard of death than non-Aboriginal people after accounting for competing risks from other causes of death, socio-demographic factors, stage and cancer site (SHR 1.40, 95%CI 1.31-1.50 for all cancers collectively). Consistent results applied to colorectal, lung, breast, prostate and other cancers. CONCLUSIONS: Aboriginal peoples with cancer have an elevated hazard of cancer death compared with non-Aboriginal people, after accounting for more advanced stage and competing causes of death. Further research is needed to determine reasons, including any contribution of co-morbidity, lifestyle factors and differentials in service access to help explain disparities.

The impact of geographic unit of analysis on socioeconomic inequalities in cancer survival and distant summary stage - a population-based study.

OBJECTIVE: When using area-level disadvantage measures, size of geographic unit can have major effects on recorded socioeconomic cancer disparities. This study examined the extent of changes in recorded socioeconomic inequalities in cancer survival and distant stage when the measure of socioeconomic disadvantage was based on smaller Census Collection Districts (CDs) instead of Statistical Local Areas (SLAs). METHODS: Population-based New South Wales Cancer Registry data were used to identify cases diagnosed with primary invasive cancer in 2000-2008 (n=264,236). Logistic regression and competing risk regression modelling were performed to examine socioeconomic differences in odds of distant stage and hazard of cancer death for all sites combined and separately for breast, prostate, colorectal and lung cancers. RESULTS: For all sites collectively, associations between socioeconomic disadvantage and cancer survival and distant stage were stronger when the CD-based socioeconomic disadvantage measure was used compared with the SLA-based measure. The CD-based measure showed a more consistent socioeconomic gradient with a linear upward trend of risk of cancer death/distant stage with increasing socioeconomic disadvantage. Site-specific analyses provided similar findings for the risk of death but less consistent results for the likelihood of distant stage. CONCLUSIONS: The use of socioeconomic disadvantage measure based on the smallest available spatial unit should be encouraged in the future. Implications for public health: Disadvantage measures based on small spatial units can more accurately identify socioeconomic cancer disparities to inform priority settings in service planning.

The Pattern of Use of Hypofractionated Radiation Therapy for Early-Stage Breast Cancer in New South Wales, Australia, 2008 to 2012.

PURPOSE: Increasing phase 3 evidence has been published about the safety and efficacy of hypofractionated radiation therapy, in comparison with standard fractionation, in early-stage, node-negative breast cancer. However, uptake of hypofractionation has not been universal. The aim of this study was to investigate the hypofractionation regimen variations in practice across public radiation oncology facilities in New South Wales (NSW). METHODS AND MATERIALS: Patients with early breast cancer registered in the NSW Clinical Cancer Registry who received radiation therapy for early-stage breast cancer in a publicly funded radiation therapy department between 2008 and 2012 were identified. Data extracted and analyzed included dose and fractionation type, patient age at first fraction, address (for geocoding), year of diagnosis, year of treatment, laterality, and department of treatment. A logistic regression model was used to identify factors associated with fractionation type. RESULTS: Of the 5880 patients fulfilling the study criteria, 3209 patients (55%) received standard fractionation and 2671 patients (45%) received hypofractionation. Overall, the use of hypofractionation increased from 37% in 2008 to 48% in 2012 (range, 7%-94% across departments). Treatment facility and the radiation oncologist prescribing the treatment were the strongest independent predictors of hypofractionation. Weaker associations were also found for age, tumor site laterality, year of treatment, and distance to facility. CONCLUSIONS: Hypofractionated regimens of whole breast radiation therapy have been variably administered in the adjuvant setting in NSW despite the publication of long-term trial results and consensus guidelines. Some factors that predict the use of hypofractionation are not based on guideline recommendations, including lower rates of left-sided treatment and increasing distance from a treatment facility.

Differences in impact of Aboriginal and Torres Strait Islander status on cancer stage and survival by level of socio-economic disadvantage and remoteness of residence-A population-based cohort study in Australia.

BACKGROUND: Aboriginal and Torres Strait Islander people (referred to in this paper as "Aboriginal people") generally have lower cancer survivals and more advanced stages at diagnosis than non-Aboriginal people. There is conflicting evidence on whether these disparities vary by socio-economic disadvantage and geographic remoteness. This study examines variations in these disparities in New South Wales (NSW), Australia. METHODS: Data for cancers diagnosed in 2000-2008 were extracted from the NSW Cancer Registry (n=264,219). Missing Aboriginal status (13.3%) was multiply imputed. Logistic regression and competing risk regression models were used to examine likelihood of advanced summary stage and risk of cancer death among Aboriginal compared with non-Aboriginal people by socio-economic disadvantage (categorised into quintiles 1: least disadvantaged-5: most disadvantaged) and remoteness. RESULTS: Aboriginal people showed a general pattern of more advanced stage at diagnosis compared with non-Aboriginal people across socio-economic disadvantage and remoteness categories. After adjusting for demographic factors, year of diagnosis, summary stage and cancer site, Aboriginal people living outside the least disadvantaged areas had an increased risk of cancer death compared with non-Aboriginal people living in similar areas (sub-hazard ratio SHR 1.41, 95% confidence interval CI 1.09-1.81; SHR 1.59, 95%CI 1.31-1.93; SHR 1.42, 95%CI 1.22-1.64 and SHR 1.34, 95%CI 1.22-1.48 for quintiles 2-5, respectively). Compared with non-Aboriginal people, Aboriginal people had an elevation in the risk of cancer death irrespective of the remoteness, with the most pronounced elevations detected in remote/very remote areas (SHR 1.56, 95%CI 1.10-2.21). CONCLUSION: Compared with non-Aboriginal people, Aboriginal people had a higher risk of cancer death and higher likelihood of more advanced stage across socio-economic disadvantage and remoteness categories. All areas appear to require attention in endeavours to improve cancer survival outcomes for Aboriginal people.

Socio-demographic disadvantage and distant summary stage of cancer at diagnosis--A population-based study in New South Wales.

BACKGROUND: Past studies generally indicate that socio-demographic disadvantage is associated with lower cancer survival but evidence of an association with stage of cancer at diagnosis has been less consistent. This study examines the associations between distant summary stage and remoteness, socio-economic status and country of birth in New South Wales for invasive cancers overall and by cancer site. METHODS: The population-based New South Wales Central Cancer Registry was used to obtain data on all cases diagnosed in 1980-2009 (n=699,382). Logistic regression models were used to compute odds ratios (ORs) with 95% confidence intervals (CIs) for odds of distant summary stage at diagnosis. RESULTS: A higher likelihood of being diagnosed with distant cancer was detected for those living in the most socio-economically disadvantaged areas compared with the least disadvantaged areas (OR 1.27, 95% CI 1.24-1.30) and for those born in other English and non-English speaking countries compared with Australian-born (OR 1.10, 95% CI 1.07-1.12 and OR 1.12, 95% CI 1.10-1.14, respectively) after adjusting for age, sex, diagnostic period, remoteness, socio-economic status and country of birth. Cases living in inner (OR 0.90, 95% CI 0.88-0.91) and outer regional (OR 0.92, 95% CI 0.89-0.94) areas were less likely to be diagnosed with distant stage than cases living in major cities. Odds of distant stage increased over time for those living in socio-economically disadvantaged areas. In cancer site-specific analyses, living in socio-economically disadvantaged areas was generally a stronger predictor of distant stage than remoteness or country of birth. CONCLUSION: Our results highlight the importance of lower socio-economic status as a predictor of distant stage at diagnosis. Socio-demographic disadvantage patterns varied for specific cancers, but in general, policy actions are recommended that emphasize earlier detection of cancers in people from lower socio-economic areas.

Changing roles of population-based cancer registries in Australia.

Registries have key roles in cancer incidence, mortality and survival monitoring and in showing disparities across the population. Incidence monitoring began in New South Wales in 1972 and other jurisdictions soon followed. Registry data are used to evaluate outcomes of preventive, screening, treatment and support services. They have shown decreases in cancer incidence following interventions and have been used for workforce and other infrastructure planning. Crude markers of optimal radiotherapy and chemotherapy exist and registry data are used to show shortfalls against these markers. The data are also used to investigate cancer clusters and environmental concerns. Survival data are used to assess service performance and interval cancer data are used in screening accreditation. Registries enable determination of risk of multiple primary cancers. Clinical quality registries are used for clinical quality improvement. Population-based cancer registries and linked administrative data complement clinical registries by providing high-level system-wide data. The USA Commission on Cancer has long used registries for quality assurance and service accreditation. Increasingly population-based registry data in Australia are linked with administrative data on service delivery to assess system performance. Addition oftumour stage and otherprognostic indicators is important forthese analyses and is facilitated by the roll-out of structured pathology reporting. Data linkage with administrative data, following checks on the quality of these data, enables assessment of patterns of care and other performance indicators for health-system monitoring. Australian cancer registries have evolved and increasingly are contributing to broader information networks for health system management.

Survival from breast, colon, lung, ovarian and rectal cancer by geographical remoteness in New South Wales, Australia, 2000-2008.

OBJECTIVE: This study aims to compare survival from breast, colon, lung, ovarian and rectal cancer by geographical remoteness in New South Wales (NSW). DESIGN: Retrospective population-wide registry study. SETTING: NSW, Australia. PARTICIPANTS: A total of 107 060 NSW residents, who were diagnosed with any of the five cancers between 01 January 2000 and 31 December 2008. MAIN OUTCOME MEASURES: Kaplan-Meier survival curves and proportional hazards regression were used to compare survival by geographical remoteness of residence at diagnosis, controlling for gender, age and extent of disease at diagnosis. Remoteness was classified using standard definitions: major city, inner regional (InnReg), outer regional (OutReg) and remote (including very remote). RESULTS: Significant differences in survival (likelihood of death) were identified in all five cancers: breast (adjusted hazard ratio(HR) = 1.22 (95% confidence interval (CI), 1.001-1.48) in regionalised and HR = 1.30 (1.02-1.64) in metastatic disease for OutReg areas); colon (HR = 1.14 (1.01-1.29) for OutReg areas in metastatic disease); lung (HR range = 1.08-1.35 (1.01-1.48) for most non-metropolitan areas in all stages of disease excepting regionalised); ovarian (HR = 1.32 (1.06-1.65) for OutReg areas in metastatic disease, HR = 1.40 (1.04-1.90) for InnReg areas and HR = 1.68 (1.02-2.77) for OutReg areas in unknown stage of disease) and rectal (HR = 1.37 (1.05-1.78) for OutReg areas in localised and HR = 1.14 (1.002-1.30) for InnReg areas in regionalised disease). Where significant differences were found, major cities tended to show the best survival, whereas OutReg areas tended to show the worst. Although no definitive interpretation could be made regarding remote areas due to small patient numbers, their survival appeared relatively favourable. CONCLUSIONS: Reasons that contribute to the differences observed and the disparate results between cancer types need to be further explored in order to facilitate targeted solutions in reducing survival inequality between NSW regions.

What factors are predictive of surgical resection and survival from localised non-small cell lung cancer?

OBJECTIVE: To investigate opportunities to reduce lung cancer mortality after diagnosis of localised non-small cell lung cancer (NSCLC) in New South Wales through surgical resection. DESIGN, PATIENTS AND SETTING: In this cohort study, resection rates and lung cancer mortality risk were explored using multivariate logistic regression and competing risk regression, respectively. Data for 3040 patients were extracted from the NSW Central Cancer Registry for the diagnostic period 1 January 2003 to 31 December 2007. Subset analyses for patients at low surgical risk indicated resection rates and outcomes under ideal circumstances. MAIN OUTCOME MEASURES: Resection rates and lung cancer mortality. RESULTS: The resection rate in NSW was estimated to be between 38% and 43%, peaking at 59% by local health district (LHD) of residence. Not having a resection was associated with older age, lower socioeconomic status, lack of private health insurance, and residence by LHD. Adjusted 5-year cumulated probabilities of death were 76% in absence of resection, 30% for wedge resection, 18% for segmental resection, 22% for lobectomy and 45% for pneumonectomy. Of 255 "low surgical risk" patients, 71% had a resection. Those not receiving a resection had a higher probability of death (adjusted subhazard ratio, 14.1; 95% CI, 7.2-27.5). If the low overall resection rate of 38%-43% in NSW were increased to 59% (the highest LHD resection rate), the proportion of all patients with localised NSCLC dying of NSCLC in the 5 years from diagnosis would decrease by about 10%, based on differences in probabilities of death by resection estimated in this study. CONCLUSIONS: Potential exists to reduce deaths from NSCLC in NSW through increased resection.

Bi-specific TCR-anti CD3 redirected T-cell targeting of NY-ESO-1- and LAGE-1-positive tumors.

NY-ESO-1 and LAGE-1 are cancer testis antigens with an ideal profile for tumor immunotherapy, combining up-regulation in many cancer types with highly restricted expression in normal tissues and sharing a common HLA-A*0201 epitope, 157-165. Here, we present data to describe the specificity and anti-tumor activity of a bifunctional ImmTAC, comprising a soluble, high-affinity T-cell receptor (TCR) specific for NY-ESO-1157-165 fused to an anti-CD3 scFv. This reagent, ImmTAC-NYE, is shown to kill HLA-A2, antigen-positive tumor cell lines, and freshly isolated HLA-A2- and LAGE-1-positive NSCLC cells. Employing time-domain optical imaging, we demonstrate in vivo targeting of fluorescently labelled high-affinity NYESO-specific TCRs to HLA-A2-, NY-ESO-1157-165-positive tumors in xenografted mice. In vivo ImmTAC-NYE efficacy was tested in a tumor model in which human lymphocytes were stably co-engrafted into NSG mice harboring tumor xenografts; efficacy was observed in both tumor prevention and established tumor models using a GFP fluorescence readout. Quantitative RT-PCR was used to analyze the expression of both NY-ESO-1 and LAGE-1 antigens in 15 normal tissues, 5 cancer cell lines, 10 NSCLC, and 10 ovarian cancer samples. Overall, LAGE-1 RNA was expressed at a greater frequency and at higher levels than NY-ESO-1 in the tumor samples. These data support the clinical utility of ImmTAC-NYE as an immunotherapeutic agent for a variety of cancers.

Competing risk analysis of mortality from invasive cutaneous melanoma in New South Wales: a population-based study, 1988-2007.

OBJECTIVE: Accurate estimates of risk of death from melanoma, based on the most recent information, are desirable, especially if secular improvements in survival have occurred. This study aims to investigate prognostic factors and temporal changes in mortality from primary invasive cutaneous melanoma (CM) and to predict cumulative probabilities of death from CM. METHODS: Cases of CM from the NSW Central Cancer Registry (NSWCCR) diagnosed in 1988-2007 were analysed. We used Fine and Gray competing risks models to investigate prognostic factors associated with CM mortality, along with period effects of year of diagnosis. Adjusted cumulative probabilities of CM death were then estimated. RESULTS: Of 52,330 CM cases, 5291 (10%) died from CM and 8290 (16%) from other causes. Patients with tumours thicker than 4 mm had 9.5 times the risk of death from CM compared to those with tumours 1 mm or less (subhazard ratio [SHR] 9.52; 95%CI:8.42-10.77). Risk of melanoma death was 31% lower in 2003-2007 compared to 1988-1992 (SHR 0.69; 95%CI: 0.63-0.76). Other risk factors for CM mortality included older age and male gender. Assuming the estimated period effect for a diagnosis in 2003-2007 applies now, the predicted probability of CM death within 10 years of diagnosis of a tumour 4+ mm thick is 26% in males and 19% in females. CONCLUSION: This study highlights the importance of awareness and early detection and shows a significant improvement in survival from CM since 1988.

Enhanced reporting of deaths among Aboriginal and Torres Strait Islander peoples using linked administrative health datasets.

BACKGROUND: Aboriginal and Torres Strait Islander peoples are under-reported in administrative health datasets in NSW, Australia. Correct reporting of Aboriginal and Torres Strait Islander peoples is essential to measure the effectiveness of policies and programmes aimed at reducing the health disadvantage experienced by Aboriginal and Torres Strait Islander peoples. This study investigates the potential of record linkage to enhance reporting of deaths among Aboriginal and Torres Strait Islander peoples in NSW, Australia. METHODS: Australian Bureau of Statistics death registration data for 2007 were linked with four population health datasets relating to hospitalisations, emergency department attendances and births. Reporting of deaths was enhanced from linked records using two methods, and effects on patterns of demographic characteristics and mortality indicators were examined. RESULTS: Reporting of deaths increased by 34.5% using an algorithm based on a weight of evidence of a person being Aboriginal or Torres Strait Islander, and by 56.6% using an approach based on 'at least one report' of a person being Aboriginal or Torres Strait Islander. The increase was relatively greater in older persons and those living in less geographically remote areas. Enhancement resulted in a reduction in the urban-remote differential in median age at death and increases in standardised mortality ratios particularly for chronic conditions. CONCLUSIONS: Record linkage creates a statistical construct that helps to correct under-reporting of deaths and potential bias in mortality statistics for Aboriginal and Torres Strait Islander peoples.

Estimates of cancer incidence, mortality and survival in aboriginal people from NSW, Australia.

BACKGROUND: Aboriginal status has been unreliably and incompletely recorded in health and vital registration data collections for the most populous areas of Australia, including NSW where 29% of Australian Aboriginal people reside. This paper reports an assessment of Aboriginal status recording in NSW cancer registrations and estimates incidence, mortality and survival from cancer in NSW Aboriginal people using multiple imputation of missing Aboriginal status in NSW Central Cancer Registry (CCR) records. METHODS: Logistic regression modelling and multiple imputation were used to assign Aboriginal status to those records of cancer diagnosed from 1999 to 2008 with missing Aboriginality (affecting 12-18% of NSW cancers registered in this period). Estimates of incidence, mortality and survival from cancer in NSW Aboriginal people were compared with the NSW total population, as standardised incidence and mortality ratios, and with the non-Aboriginal population. RESULTS: Following imputation, 146 (12.2%) extra cancers in Aboriginal males and 140 (12.5%) in Aboriginal females were found for 1999-2007. Mean annual cancer incidence in NSW Aboriginal people was estimated to be 660 per 100,000 and 462 per 100,000, 9% and 6% higher than all NSW males and females respectively. Mean annual cancer mortality in NSW Aboriginal people was estimated to be 373 per 100,000 in males and 240 per 100,000 in females, 68% and 73% higher than for all NSW males and females respectively. Despite similar incidence of localised cancer, mortality from localised cancer in Aboriginal people is significantly higher than in non-Aboriginal people, as is mortality from cancers with regional, distant and unknown degree of spread at diagnosis. Cancer survival in Aboriginal people is significantly lower: 51% of males and 43% of females had died of the cancer by 5 years following diagnosis, compared to 36% and 33% of non-Aboriginal males and females respectively. CONCLUSION: The present study is the first to produce valid and reliable estimates of cancer incidence, survival and mortality in Australian Aboriginal people from NSW. Despite somewhat higher cancer incidence in Aboriginal than in non-Aboriginal people, substantially higher mortality and lower survival in Aboriginal people is only partly explained by more advanced cancer at diagnosis.

Surgical outcomes associated with oesophagectomy in New South Wales: an investigation of hospital volume.

INTRODUCTION: Resection remains the standard treatment for curable oesophageal cancer. By linking the NSW Central Cancer Registry (CCR) and the NSW Admitted Patient Data Collection (APDC) databases, mortality, post-resection complication and survival associated with oesophagectomy were investigated. METHODS: All patients diagnosed with oesophageal cancer from 2000 to 2005 as recorded in the CCR (n = 2,082) were linked with records in the APDC, giving a total of 17,205 episodes of care. Over 15% (n = 321) of all patients underwent an oesophagectomy. RESULTS AND DISCUSSION: The overall 30-day mortality rate following resection was 3.7%, ranging from 2.6% in high volume hospitals to 6.4% in low volume hospitals. Three-year absolute survival for localised-regional disease following oesophagectomy was 64% (95%CI 54-73%) in high-volume hospitals, 58% (95%CI 46-68%) in mid-volume and 45% (95%CI 23-65%) in low-volume hospitals. The post-resection complication rate was 19% (95%CI 13-26%) for high-volume hospital, 24% (95%CI 13-40%) in low-volume and 31% (95%CI 22-41%) in mid-volume hospitals. CONCLUSION: Oesophagectomy in NSW is performed with satisfactory results. However, there is a suggestion that higher- rather than lower-volume hospitals have better post-resection outcomes.

Adenocarcinoma of the oesophagus: incidence and survival rates in New South Wales, 1972-2005.

OBJECTIVE: To investigate trends in the incidence of adenocarcinoma (AC) of the oesophagus in New South Wales, factors associated with a diagnosis of AC, and factors associated with survival of patients with AC. DESIGN AND SETTING: We examined all cases of invasive oesophageal cancer recorded in the NSW Central Cancer Registry from 1972 to 2005. The Accessibility/Remoteness Index of Australia was used to assess geographical remoteness and the Index of Relative Socio-Economic Disadvantage to assess socioeconomic status. MAIN OUTCOME MEASURES: Incidence of AC; factors associated with diagnosis of AC and survival of patients with AC. RESULTS: The overall incidence of oesophageal AC in NSW increased in both males and females (annual percentage change, 4.2% [95% CL, 2.7%, 5.8%] in males [1988-2005] and 4.3% [95% CL, 1.8%, 7.0%] in females [1983-2005]). A diagnosis of AC was significantly associated with being male (adjusted odds ratio [AOR], 4.37 [95% CL, 3.84, 4.98]; P < 0.001); a younger age at diagnosis (P trend < 0.001); having distant rather than localised disease spread (AOR, 2.12 [95% CL, 1.82, 2.48]; P < 0.001); higher socioeconomic status (P trend < 0.001); and living in an inner regional area (AOR, 1.26 [95% CL, 1.11, 1.43]; P < 0.001) or outer regional area (AOR, 1.19 [95% CL, 1.00, 1.41]; P = 0.05) compared with a major city. Early diagnosis of AC was associated with substantial improvement in survival outcomes: patients with metastatic disease at diagnosis had a three times greater risk of dying than those with localised AC at diagnosis. CONCLUSION: The incidence of AC is increasing in NSW. Possible contributing factors include increasing obesity, which is associated with increased incidence of gastro-oesophageal reflux disease. Survival may be improved by diagnosis at an earlier stage and changes in modifiable risk factors (eg, smoking, diet, exercise).