Population-based screening for Lynch syndrome in Western Australia.

We showed earlier that routine screening for microsatellite instability (MSI) and loss of mismatch repair (MMR) protein expression in colorectal cancer (CRC) led to the identification of previously unrecognized cases of Lynch syndrome (LS). We report here the results of screening for LS in Western Australia (WA) during 1994-2012. Immunohistochemistry (IHC) for loss of MMR protein expression was performed in routine pathology laboratories, while MSI was detected in a reference molecular pathology laboratory. Information on germline mutations in MMR genes was obtained from the state's single familial cancer registry. Prior to the introduction of routine laboratory-based screening, an average of 2-3 cases of LS were diagnosed each year amongst WA CRC patients. Following the implementation of IHC and/or MSI screening for all younger (<60 years) CRC patients, this has increased to an average of 8 LS cases diagnosed annually. Based on our experience in WA, we propose three key elements for successful population-based screening of LS. First, for all younger CRC patients, reflex IHC testing should be carried out in accredited pathology services with ongoing quality control. Second, a state- or region-wide reference laboratory for MSI testing should be established to confirm abnormal or suspicious IHC test results and to exclude sporadic cases by carrying out BRAF mutation or MLH1 methylation testing. Finally, a state or regional LS coordinator is essential to ensure that all appropriate cases identified by laboratory testing are referred to and attend a Familial Cancer Clinic for follow-up and germline testing.

Nausea still the poor relation in antiemetic therapy? The impact on cancer patients' quality of life and psychological adjustment of nausea, vomiting and appetite loss, individually and concurrently as part of a symptom cluster.

PURPOSE: Despite significant antiemetic advances, almost 50% of treated cancer patients still experience nausea and vomiting (N&V). The goal of antiemetic therapy--complete prevention of treatment-induced nausea and/or vomiting (TIN+/-V)--remains elusive for several reasons. Potentially, N&V may be part of a symptom cluster where co-occurring symptoms negatively affect antiemetic management. Consequently, we examined TIN+/-V incidence and the impact of nausea, vomiting and symptom cluster(s) containing them, respectively, on patients' quality of life (QoL) and psychological adjustment across treatment. METHODS: A longitudinal secondary analysis was performed on data from a prospective, observational QoL study involving 200 newly diagnosed cancer patients who underwent combined modality treatment. QoL, psychological adjustment and patient/clinical characteristics were examined at pretreatment, on-treatment (8 weeks) and post-treatment. RESULTS: Overall, 62% of patients experienced TIN+/-V, with TIN (60%) doubling TIV incidence (27 %). Exploratory factor analyses of QoL scores at each treatment time point identified a recurrent gastrointestinal symptom cluster comprising nausea, vomiting and appetite loss. Approximately two thirds of patients reported co-occurrence of all three symptoms, which exerted synergistic effects of multiplicative proportions on overall QoL. Patients who reported co-occurrence of these symptoms during treatment experienced significantly greater QoL impairment (physical, role and social functioning, fatigue, N&V, appetite loss, overall physical health, overall QOL) and psychological distress (cancer distress, premorbid neuroticism) than those unaffected (0.001 > p ≤ 0.05). Moreover, nausea was more pervasive than vomiting or appetite loss across treatment and had a greater impact on overall QoL. While antiemetic therapy was effective for vomiting and helped prevent/relieve associated appetite loss, the benefits for appetite loss were seemingly constrained by its failure to exert adequate control over nausea in many patients. CONCLUSIONS: TIN+/-V still represents a very major concern for patients. Uncontrolled TIN+/-V often results in significant appetite and weight loss, leading to increased risk for malnutrition. Malnutrition and weight loss, in turn, are associated with poorer prognosis, treatment tolerance and response, performance status, QoL and survival. Consequently, a multiple symptom intervention approach focusing on N&V as core symptoms is recommended. Clinicians should genuinely consider combining essential antiemetic therapies with other evidence-based pharmacological (e.g. nausea: psychotropics, such as olanzapine) and non-pharmacological approaches (e.g. N&V: relaxation) in attempts to not only improve prevention and control of N&V for their patients, but also reduce the synergistic impact of cluster symptoms (e.g. N&V, appetite loss) as a whole and resultant QoL impairment likewise. Where associated symptoms are not adequately controlled by these antiemetic-based interventions, targeted evidence-based strategies should be supplemented.

Risk factors at pretreatment predicting treatment-induced nausea and vomiting in Australian cancer patients: a prospective, longitudinal, observational study.

PURPOSE: Despite significant advances in antiemetic management, almost 50% of cancer patients still experience nausea and vomiting during treatment. The goal of antiemetic therapy is complete prevention of treatment-induced nausea and/or vomiting (TINV); however, realisation of this goal remains elusive, thus supplementary strategies identifying patients at high risk must be employed in the interim. Consequently, we examined TINV incidence and its risk factors, including patient, clinical and pretreatment quality of life (QOL)/psychological factors. METHODS: Two hundred newly diagnosed cancer patients beginning combined treatment participated in this prospective, longitudinal, observational study. QOL (including TINV), psychological adjustment, and patient/clinical characteristics were examined at pretreatment, on-treatment (8 weeks ± 1 week) and post-treatment. RESULTS: Overall, 62% of patients experienced TINV, with TIN incidence (60%) doubling that of TIV (27%). Eight independent risk factors predicted 73% of TIN incidence: high premorbid/anticipatory NV, moderately/highly emetogenic chemotherapy (M/HEC), longer treatment (>3 months), female gender, surgery prior to adjuvant chemotherapy ± radiotherapy, private health insurance and low emotional functioning (pretreatment). Six independent risk factors predicted 77% of TIV incidence: premorbid/anticipatory vomiting, M/HEC, female gender, cancer resection and low role functioning (pretreatment). CONCLUSIONS: TINV still represents a very major concern for patients. Several pretreatment risk factors for the development of TIN and TIV, respectively, were identified. Patients about to undergo cancer treatment, particularly combined treatment involving emetogenic chemotherapy and surgery, should be screened for these factors with a view to modifying standard pretreatment/maintenance antiemetic therapy. Furthermore, and consistent with recent research, it is recommended that more comprehensive interventions combining antiemetics with other effective pharmacological (e.g. anxiolytics) and non-pharmacological approaches (e.g. acupuncture, relaxation techniques) be considered by clinicians in attempts to improve control of TIN and TIV (and overall QOL) for their patients. In this way, optimal holistic care will be ensured for cancer patients by clinicians providing conventional oncology treatment.

Unmet psychological and practical needs of patients with cancer in rural and remote areas of Western Australia.

INTRODUCTION: The financial and psychological impacts of cancer treatment on patients can be severe. Practical issues, such as childcare, medical supplies and obtaining 'home help' can impose financial strain on patients and their families, and this is often exacerbated by a simultaneous loss of income if a patient is unable to continue employment during treatment, or if family members become full-time carers. These financial difficulties are often more severe for patients from rural regions because cancer services tend to be concentrated in metropolitan areas, requiring rural patients to relocate or undertake lengthy, frequent commutes to access treatment. The needs of rural cancer patients may differ from and exceed those of metropolitan cancer patients. Because of this, it is important to assess the needs of rural and metropolitan populations to develop appropriate, tailored supportive-care interventions. This article compares the unmet supportive-care needs of rural/remote with metropolitan cancer patients in Western Australia (WA), a large and sparsely populated Australian state with a substantial rural and remote population. This article is part of a larger program of research assessing the supportive-care needs of WA cancer patients. METHODS: Participants were identified through the Western Australian Cancer Registry (WACR) and considered eligible if diagnosed with any type of cancer between 6 months and 2 years previously. A random sample of 2079 potential participants was generated, structured to include all cancer types and geographical areas, and with both sexes randomised within these groups. Following confirmation and exclusion of deceased patients and those patients excluded at the treating doctor's request, 1770 patients were contacted. Participants were asked to complete a demographic questionnaire and the Supportive Care Needs Survey Long Form (SCNS-59). Data from participants who completed and returned both questionnaires were analysed using descriptive statistics and χ(2) tests; and any missing data were addressed through imputation. RESULTS: Eight hundred and twenty-nine participants (47% response) completed the SCNS-LF59 and 786 (94.8%) completed both questionnaires. Of the 786 respondents, 234 (30%) were from rural areas and 169 (22%) were from remote areas. Among the 15 items with the highest frequency for 'some needs' on the survey, participant needs did not vary by geographical location, with no significant differences found for any of the 15 items. The item for which the greatest, albeit non-significant (p = 0.12) difference was seen, was 'concern about financial situation'. The differences among all other items were not significant (p-values from 0.28 to 0.96). Furthermore, the proportion of participants reporting 'moderate to high need' on these items also did not differ significantly across geographical populations (p-values from 0.13 to 0.91). CONCLUSIONS: The lack of discrepancy between rural, remote and metropolitan cancer patients' unmet needs provides a positive message regarding the state of WA cancer services and the level of support provided to rural and remote WA residents. Future research should also assess the unmet needs of rural and remote carers and families in comparison with metropolitan carers and families, to ensure that services are well-equipped to meet the needs of all individuals involved in a patient's cancer journey.

Precision in Setting Cancer Prevention Priorities: Synthesis of Data, Literature, and Expert Opinion.

Cancer will continue to be a leading cause of ill health and death unless we can capitalize on the potential for 30-40% of these cancers to be prevented. In this light, cancer prevention represents an enormous opportunity for public health, potentially saving much of the pain, anguish, and cost associated with treating cancer. However, there is a challenge for governments, and the wider community, in prioritizing cancer prevention activities, especially given increasing financial constraints. This paper describes a method for identifying cancer prevention priorities. This method synthesizes detailed cancer statistics, expert opinion, and the published literature for the priority setting process. The process contains four steps: assessing the impact of cancer types; identifying cancers with the greatest impact; considering opportunities for prevention; and combining information on impact and preventability. The strength of our approach is that it is straightforward, transparent and reproducible for other settings. Applying this method in Western Australia produced a priority list of seven adult cancers which were identified as having not only the biggest impact on the community but also the best opportunities for prevention. Work conducted in an additional project phase went on to present data on these priority cancers to a public consultation and develop an agenda for action in cancer prevention.

Evaluating the usefulness of self-reported risk factors in a skin cancer screening program.

The objective of this study was to describe the risk factor profile of skin cancer screening participants and to determine whether there is an association between the number of skin cancer/melanoma risk factors and the likelihood of diagnosis of a malignant melanoma. Seventy skin cancer screening clinics were held by the Lions Cancer Institute in predominantly rural areas of Western Australia between 1996 and 2003. Participants were self-selected and voluntary, responding to an advertisement seeking people at 'high-risk' of melanoma. The Lions Cancer Institute skin screening clinics targeted participation by individuals with three or more of the established risk factors for skin cancer/melanoma. Questionnaires collecting information on the self-report of nine risk factors were completed by 5950 participants who were screened for melanoma between 1996 and 2003. The number and type of risk factors, and of provisionally diagnosed and histopathologically confirmed malignant melanomas were measured. Of 5950 participants, 18 histopathologically confirmed malignant melanomas were detected. A participant's total number of risk factors showed some association with the provisional melanoma diagnosis given at the time of screening. No relationship, however, was observed between the number of risk factors and a melanoma that was histopathologically confirmed after screening. The risk factor method is effective in selecting a 'high risk' population, but does not seem to have high value in predicting who will be diagnosed with melanoma as a result of screening. Further studies are needed to verify this finding owing to the rarity of melanoma and the small number of confirmed melanomas in this study.

Who attends skin cancer screening in Western Australia? Results from the Lions Cancer Institute Skin Cancer Screening Program.

OBJECTIVE: To examine the characteristics of persons attending a skin cancer screening clinic in Western Australia and compare the effectiveness of screening in different socio-demographic subgroups. METHODS: Questionnaires were completed by 5,950 self-selected participants who voluntarily attended the Western Australian Lions Cancer Institute's targeted skin cancer screening clinics during the period 1996-2003. A risk assessment technique was used to identify individuals at high risk of developing melanoma. Provisional diagnoses of suspicious lesions were given at the screening by a medical specialist. Suspicious lesions were later matched with histopathologically confirmed malignant melanomas reported to the Western Australia Cancer Registry. RESULTS: Fifty-seven per cent of attendees were female. The mean age of attendees was 53 years. The yield of suspicious malignant melanomas detected was 24.7 per 1,000 participants screened; the yield of confirmed malignant melanomas detected was 3.0 per 1,000 participants screened. Persons over 50 years of age were three times more likely to have a histopathologically confirmed malignant melanoma detected at the screening than those younger than 50 years (p = 0.049). CONCLUSIONS: The yield of confirmed melanomas detected by the Lions Cancer Institute is among the highest reported by a skin cancer screening program. This may have been attributable to the risk assessment technique used by the program. IMPLICATIONS: A free community skin cancer screening program that targets high-risk individuals can detect melanomas.

Collection of population-based cancer staging information in Western Australia--a feasibility study.

BACKGROUND: Routine data from cancer registries often lack information on stage of cancer, limiting their use. This study aimed to determine whether or not it is feasible to add cancer staging data to the routine data collections of a population-based Western Australian Cancer Registry (WACR). METHODS: For each of the five most common cancer types (prostate, colorectal, melanoma, breast and lung cancers), 60 cases were selected for staging. For the 15 next most common cancer types, 20 cases were selected. Four sources for collecting staging data were used in the following order: the WACR, the hospital based cancer registries (HBCRs), hospital medical records, and letters to treating doctors. If the case was unable to be fully staged, due to lack of information on regional lymph node invasion or distant metastases, we made the following assumptions. Cases which had data available for tumour (T) and regional lymph nodes (N), but no assessment of distant metastasis (MX) were assumed to have no distant metastases (M0). Cases which had data for T and M, but no assessment of regional nodal involvement (NX) were assumed to have no regional nodal involvement (N0). RESULTS: The main focus of this project was the process of collecting staging data, and not the outcomes. For ovary, cervix and uterus cancers the existence of a HBCR increased the stageable proportion of cases so that staging data for these cancers could be incorporated into the WACR immediately. Breast and colorectal cancer could also be staged with adequate completeness if it were assumed that MX = M0. Similarly, melanoma and prostate cancer could be staged adequately if it were assumed that NX = N0 and MX = M0. Some cases of stomach, lung, pancreas, thyroid, testis and kidney cancers could be staged, but additional clinical input--on pathology request forms, for example--would be required to achieve useable levels of completeness. For the remaining cancer types either staging is widely regarded as not relevant, and no generally-accepted system exists, or an acceptable level of completeness is not achievable. CONCLUSION: Adding stage to routinely collected information in a cancer registry is possible for many cancer types, particularly if the assumptions regarding missing data are found to be acceptable or if the guidelines for MX = M0 assumptions are clarified. These findings should be generalizable to most cancer registries in developed countries, if hospital-based cancer registries or other specialized databases are accessible.

Clinical Oncology Society of Australia position statement on the use of complementary and alternative medicine by cancer patients.

Health professionals involved in the clinical management of cancer are becoming increasingly aware that their patients use complementary and alternative medicine (CAM). As cancer incidence and survival rates increase, use of CAM is also likely to increase. This paper outlines the position of the Clinical Oncology Society of Australia (COSA) on the use of CAM by cancer patients and provides guidance for health professionals involved with the treatment of cancer patients who are using or wish to use CAM. Key definitions and common communication scenarios are presented along with evidence-based recommended steps for health professionals when discussing CAM use. COSA encourages health professionals to focus on open discussion with their patients regarding CAM, to become familiar with reputable resources for CAM information, to discuss with patients the concept of evidence-based medicine, to recognize limitations to their knowledge of CAM and seek further advice when necessary, and to be respectful of the patients' right to autonomy.

Validity of melanoma diagnosis in a community-based screening program.

Although screening for melanoma is intuitively attractive, evidence of the effectiveness of screening programs for skin cancer is lacking. Since 1990, the Lions Cancer Institute has conducted clinics in Western Australia in which volunteer plastic surgeons and dermatologists undertake full-body skin screens. Advertisements for attendees target people with risk factors for skin cancer. Each person screened between 1994 and 2002 (n = 7,436) completed a questionnaire including basic demographic information, on which the physician added provisional diagnoses. Attendees' details were linked with the Western Australian Cancer Registry to determine the number of diagnosed melanomas up to 1 and 2 years after screening. The positive predictive value of a screening diagnosis of "any lesion" at a particular body site was 1.5% and that of a screening diagnosis of "melanoma" was 10.0%. The 1-year specificity of the screening test ranged from 95.1% to 99.5%, and 1-year sensitivity ranged from 63.6% to 81.8%. Two-year sensitivity was lower. If body site was not taken into account, the sensitivities were higher and the specificities lower. Findings suggest that the validity of skin screening diagnoses in the general population is reasonable. Body site of the lesion should be taken into account when calculating validity of these diagnoses.