"Lest we forget": An overview of Australia's response to the recovery and identification of unrecovered historic military remains.

The Australian Defence Force (ADF) is responsible for the recovery and identification of its historic casualties. With over 30,000 still unrecovered from past conflicts including World War One (WW1) and World War Two (WWII), the Australian Army and Royal Australian Air Force have teams that research, recover, identify and oversee the burial (or reburial) of the remains of soldiers and airmen who continue to be found each year. The Royal Australian Navy is also responsible for its unrecovered casualties. Collectively the priorities of the various services within the ADF are the respectful recovery and treatment of the dead, thorough forensic identification efforts, resolution for families and honouring the ADF's proud history of service and sacrifice. What is unique about the approach of the ADF is that the respective services retain responsibility for their historic losses, while a joint approach is taken on policies and in the utilisation of the pool of forensic specialists. Section One describes the process undertaken by the Australian Army in the recovery, identification and burial or repatriation of soldiers through its specialised unit Unrecovered War Casualties - Army (UWC-A). Section Two describes the role of the Royal Australian Air Force in the recovery of aircraft and service personnel through their specialised unit Historic Unrecovered War Casualties - Air Force (HUWC-AF). An overview of the operations of each service and case studies is presented for each section.

The validity of the Distress Thermometer in female partners of men with prostate cancer.

Female partners of prostate cancer (PCa) survivors experience heightened psychological distress that may be greater than that expressed by PCa patients. However, optimal approaches to detect distressed, or at risk of distress, partners are unclear. This study applied receiver operating characteristics analysis to evaluate diagnostic accuracy, sensitivity and specificity of the Distress Thermometer (DT) compared to widely used measures of general (Hospital Anxiety and Depression Scale) and cancer-specific (Impact of Events Scale-Revised) distress. Participants were partners of men with localised PCa (recruited around diagnosis) about to undergo or had received surgical treatment (N = 189), and partners of men diagnosed with PCa who were 2-4 years post-treatment (N = 460). In both studies, diagnostic utility of the DT overall was not optimal. Although area under the curve scores were acceptable (ranges: 0.71-0.92 and 0.83-0.94 for general and cancer-specific distress, respectively), sensitivity, specificity and optimal DT cut-offs for partner distress varied for general (range: ≥2 to ≥5) and cancer-specific (range: ≥3 to ≥5) distress both across time and between cohorts. Thus, it is difficult to draw firm conclusions about the diagnostic capabilities of the DT for partners or recommend its use in this population. More comprehensive screening measures may be needed to detect partners needing psychological intervention.

Predicting 7-year mortality for use with evidence-based guidelines for Prostate-Specific Antigen (PSA) testing: findings from a large prospective study of 123 697 Australian men.

OBJECTIVES: To develop and validate a prediction model for short-term mortality in Australian men aged ≥45years, using age and self-reported health variables, for use when implementing the Australian Clinical Practice Guidelines for Prostate-Specific Antigen (PSA) Testing and Early Management of Test-Detected Prostate Cancer. Implementation of one of the Guideline recommendations requires an estimate of 7-year mortality. DESIGN: Prospective cohort study using questionnaire data linked to mortality data. SETTING: Men aged ≥45years randomly sampled from the general population of New South Wales, Australia, participating in the 45 and Up Study. PARTICIPANTS: 123 697 men who completed the baseline postal questionnaire (distributed from 1 January 2006 to 31 December 2008) and gave informed consent for follow-up through linkage of their data to population health databases. PRIMARY OUTCOME MEASURES: The primary outcome was all-cause mortality. RESULTS: 12 160 died during follow-up (median=5.9 years). Following age-adjustment, self-reported health was the strongest predictor of all-cause mortality (C-index: 0.827; 95% CI 0.824 to 0.831). Three prediction models for all-cause mortality were validated, with predictors: Model-1: age group and self-rated health; Model-2: variables common to the 45 and Up Study and the Australian Health Survey and subselected using stepwise regression and Model-3: all variables selected using stepwise regression. Final predictions calibrated well with observed all-cause mortality rates. The 90th percentile for the 7-year mortality risks ranged from 1.92% to 83.94% for ages 45-85 years. CONCLUSIONS: We developed prediction scores for short-term mortality using age and self-reported health measures and validated the scores against national mortality rates. Along with age, simple measures such as self-rated health, which can be easily obtained without physical examination, were strong predictors of all-cause mortality in the 45 and Up Study. Seven-year mortality risk estimates from Model-3 suggest that the impact of the mortality risk prediction tool on men's decision making would be small in the recommended age (50-69 years) for PSA testing, but it may discourage testing at older ages.

Experiences of Australian men diagnosed with advanced prostate cancer: a qualitative study.

OBJECTIVE: To explore men's lived experience of advanced prostate cancer (PCa) and preferences for support. DESIGN: Cross-sectional qualitative study applying open-ended surveys and interviews conducted between June and November 2016. Interviews audio-recorded and transcribed verbatim and analysed from an interpretive phenomenological perspective. SETTING: Australia, nation-wide. PARTICIPANTS: 39 men diagnosed with advanced PCa (metastatic or castration-resistant biochemical regression) were surveyed with 28 men subsequently completing a semistructured in depth telephone interview. RESULTS: Thematic analysis of interviews identified two organising themes: lived experience and supportive care. Lived experience included six superordinate themes: regret about late diagnosis and treatment decisions, being discounted in the health system, fear/uncertainty about the future, acceptance of their situation, masculinity and treatment effects. Supportive care included five superordinate themes: communication, care coordination, accessible care, shared experience/peer support and involvement of their partner/family. CONCLUSIONS: Life course and the health and social context of PCa influence men's experiences of advanced disease. Multimodal interventions integrating peer support and specialist nurses are needed that more closely articulate with men's expressed needs.

Estimating the healthcare costs of treating prostate cancer in Australia: A Markov modelling analysis.

PURPOSE: To estimate the health system costs of prostate cancer by disease risk category and treatment type over 2016 to 2025 and to identify potential strategies to contain the cost increase. METHODS: A Markov cohort model was developed using clinical pathways from US prostate cancer guidelines and clinical expertise. Estimates of the probabilities of various treatments and outcomes and their unit costs were sourced from systematic reviews, meta-analyses, epidemiological publications and national cost reports. Estimated costs by stage of disease, by major treatments and by age at diagnosis were reported in 2016 US dollars. One-way and probabilistic sensitivity analyses assessed potential variation in the modeled costs. RESULTS: Australia-wide costs of prostate cancer were estimated at US$270.9 million in 2016 rising to US$384.3 million in 2025, an expected increase of 42%. Of this total increase, newly diagnosed low risk cases will contribute US$32.9 million, intermediate-risk US$56.8 million, high-risk US$53.3 million and advanced US$12.6 million. For men diagnosed at age 65 with low-risk disease, lifetime costs per patient were US$14,497 for surgery, US$19,665 for radiation therapies to the primary lesion, and US$9,234 for active surveillance. For intermediate- or high-risk disease, mean costs per patient were US$34,941 for surgery plus radiation and US$31,790 for androgen deprivation therapy plus radiation while advanced cancer therapies were at US$31,574 per patient. Additional costs for managing iatrogenic disease secondary to these treatments were excluded. CONCLUSION: Strategies for identifying patients early before cancers have spread are critical to contain the estimated 42% increase in costs over the next decade. Increased uptake of active surveillance would also lead to substantial cost-savings in the management of low-risk prostate cancer.

What does it cost Medicare to diagnose and treat men with localized prostate cancer in the first year?

OBJECTIVE: To estimate costs on the Medicare Benefits Schedule (MBS) and the Pharmaceutical Benefits Scheme (PBS) attributable to the diagnosis and treatment of prostate cancer. METHODS: We used data from a cohort study of 1064 men with localized prostate cancer recruited between 2005 and 2007 by 24 urologists across 10 sites in Queensland, Australia (ProsCan). We estimated the MBS and PBS costs attributable to prostate cancer from the date of initial appointment to 12 months after diagnosis in 2013 Australian dollars using a comparison group without prostate cancer. We used generalized linear modeling to identify key determinants of higher treatment-related costs. RESULTS: From the date of initial appointment to 12 months postdiagnosis, the average MBS costs attributable to prostate cancer were $9,357 (SD $191) per patient. These MBS costs were most sensitive to having private health insurance and the type of primary treatment received. The PBS costs were higher in the control group than in the ProsCan group ($5,641 vs $1,924). CONCLUSIONS: The costs of treating and managing prostate cancer are high and these result in a substantial financial burden for the Australian MBS. Costs attributable to prostate cancer appear to vary widely based on initial treatment and these are likely to increase with the introduction of more expensive services and pharmaceuticals. There is a pressing need for better prognostic tools to distinguish between indolent and aggressive prostate tumors to reduce potential over treatment and help ease the burden of prostate cancer.

A Systematic Review of Financial Toxicity Among Cancer Survivors: We Can't Pay the Co-Pay.

OBJECTIVE: To determine the extent of financial toxicity (FT) among cancer survivors, identify the determinants and how FT is measured. METHODS: A systematic review was performed in MEDLINE, CINAHL and PsycINFO, using relevant terminology and included articles published from 1 January, 2013 to 30 June, 2016. We included observational studies where the primary outcomes included FT and study samples were greater than 200. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were followed. RESULTS: From 417 citations, a total of 25 studies were included in this review. Seventy outcomes of FT were reported with 47 covering monetary, objective and subjective indicators of FT. A total of 28-48% of patients reported FT using monetary measures and 16-73% using subjective measures. The most commonly reported factors associated with FT were: being female, younger age, low income at baseline, adjuvant therapies and more recent diagnosis. Relative to non-cancer comparison groups, cancer survivors experienced significantly higher FT. Most studies were cross-sectional and causal inferences between FT and determinants were not possible. Measures of FT were varied and most were not validated, while monetary values of out-of-pocket expenses included different cost components across studies. CONCLUSIONS: A substantial proportion of cancer survivors experience financial hardship irrespective of how it is measured. Using standardised outcomes and longitudinal designs to measure FT would improve determination of the extent of FT. Further research is recommended on reduced work participation and income losses occurring concurrently with FT and on the impacts on treatment non-adherence.

Cost-effectiveness analysis of multiparametric MRI with increased active surveillance for low-risk prostate cancer in Australia.

PURPOSE: To evaluate the cost-effectiveness of multiparametric magnetic resonance imaging (mpMRI) to diagnose prostate cancer and direct all low-risk patients into active surveillance (AS). MATERIALS AND METHODS: A Markov cohort model was developed to assess three scenarios: 1) no mpMRI and current AS; 2) mpMRI and current AS; and 3) mpMRI and increased AS. Men were tracked from diagnosis to end-of-life. Estimates to populate the model were derived from systematic reviews, meta-analyses, epidemiological publications, and national cost reports. An Australian Government perspective was used. Outcomes included healthcare costs, survival, quality-adjusted life years (QALYs), number of biopsies, and significant and insignificant cancers. Extensive sensitivity analyses were undertaken to address possible variation in the modeled inputs. RESULTS: Mean lifetime costs per patient were AU$23,191 for Scenario 1, AU$23,387 for Scenario 2 and AU$21,064 for Scenario 3. Corresponding QALYs were 7.81, 7.77, 7.83 for Scenarios 1, 2, and 3, respectively. At the current uptake of AS in Australia, mpMRI alone does not appear cost-effective (16.9% likelihood). However, mpMRI with AS for all men with low-risk disease is strongly cost-effective (86.9% likelihood) at a willingness-to-pay AU$50,000 per QALY gained. For the mpMRI options, for every 1000 men suspected of prostate cancer, using mpMRI would avoid 340 biopsies, detect an additional 20 significant cancers, and detect 10 fewer insignificant cancers. CONCLUSION: Diagnosis of prostate cancer through mpMRI technology would be cost-effective if it leads to increased uptake of AS for men with confirmed very-low- or low-risk prostate cancer. LEVEL OF EVIDENCE: 2 J. MAGN. RESON. IMAGING 2017;45:1304-1315.

Medical Help-Seeking for Sexual Concerns in Prostate Cancer Survivors.

INTRODUCTION: Although sexual dysfunction is common after prostate cancer, men's decisions to seek help for sexual concerns are not well understood. AIM: Describe predictors of actual prior help-seeking and intended future medical help-seeking for sexual dysfunction in prostate cancer survivors. METHODS: A cross-sectional survey of 510 prostate cancer survivors assessed masculine beliefs, attitudes, support/approval from partner/peer networks (subjective norm), and perceived control as predictors of medical help-seeking for sexual concerns. A theory of planned behavior (TPB) perspective was used to examine actual prior and planned future behavior and contributing factors. Statistical analyses included multiple and logistic regressions. MAIN OUTCOME MEASURES: Intention to see a doctor for sexual advice or help in the next 6 months was measured using the intention subscale adapted from the Attitudes to Seeking Help after Cancer Scale. Prior help-seeking was measured with a dichotomous yes/no scale created for the study. RESULTS: Men were Mage 71.69 years (SD = 7.71); 7.54 years (SD = 4.68) post-diagnosis; received treatment(s) (58.1% radical prostatectomy; 47.1% radiation therapy; 29.4% hormonal ablation); 81.4% reported severe ED (IIED 0-6) and 18.6% moderate-mild ED (IIED 7-24). Overall, 30% had sought sexual help in the past 6 months, and 24% intended to seek help in the following 6 months. Prior help-seeking was less frequent among men with severe ED. Sexual help-seeking intentions were associated with lower education, prior sexual help-seeking, sexual importance/ priority, emotional self-reliance, positive attitude, and subjective norm (R(2) = 0.56). CONCLUSION: The TPB has utility as a theoretical framework to understand prostate cancer survivors' sexual help-seeking decisions and may inform development of more effective interventions. Masculine beliefs were highly salient. Men who were more emotionally self-reliant and attributed greater importance to sex formed stronger help-seeking intentions. Subjective norm contributed most strongly to help-seeking intentions suggesting that health professionals/partners/peers have a key role as support mechanisms and components of psycho-sexual interventions.

Defining young in the context of prostate cancer.

The experience of prostate cancer is for most men a major life stress with the psychological burden of this disease falling more heavily on those who are younger. Despite this, being young as it applies to prostate cancer is not yet clearly defined with varied chronological approaches applied. However, men's responses to health crises are closely bound to life course and masculinities from which social roles emerge. This paper applied qualitative methodology (structured focus groups and semistructured interviews with expert informants) using interpretative phenomenological analysis to define what it means to be young and have prostate cancer. Structured focus groups were held with 26 consumer advisors (men diagnosed with prostate cancer who provide support to other men with prostate cancer or raise community awareness) and health professionals. As well, 15 men diagnosed with prostate cancer and in their 40s, 50s, or 60s participated in semi-structured interviews. Participants discussed the attributes that describe a young man with prostate cancer and the experience of being young and diagnosed with prostate cancer. Chronological definitions of a young man were absent or inconsistent. Masculine constructions of what it means to be a young man and life course characteristics appear more relevant to defining young as it applies to prostate cancer compared with chronological age. These findings have implications for better understanding the morbidities associated with this illness, and in designing interventions that are oriented to life course and helping young men reconstruct their identities after prostate cancer.