Lessons from a population-based bladder cancer registry: exploring why survival is not improving.

OBJECTIVE: To explore the causes of the decrease in bladder cancer survival that has occurred over the past four decades. METHODS: We extracted data from the South Australian Cancer Registry. Data from the period 1 January 1977 to 31 December 2020 were extracted to explore changes in incidence and survival among a total of 8356 patients diagnosed with ≥pT1 disease. Invasive bladder cancer was defined as ≥pT1 in this study. RESULTS: Invasive bladder cancer age-standardized incidence decreased from 7.20 cases per 100 000 people in 1977 to 5.85 cases per 100 000 in 2020. The mean age at diagnosis increased from 68 years to 76 years. The crude incidence for patients aged 80 years and over increased by 3.3% per year (95% confidence interval [CI] 2.1 to 4.6). Overall survival decreased over the study period (hazard ratio [HR] 1.22 [95% CI 1.09 to 1.35]), however, survival increased after adjusting for age at diagnosis (HR 0.80 [95% CI 0.76 to 0.94]). Despite a decrease in non-bladder cancer-specific deaths in older people, there was no change in the bladder cancer-specific death rate in older people (HR 0.94 [95% CI 0.70 to 1.26]). Male sex was associated with higher survival (HR 0.87 [95% CI 0.83 to 0.92]), whereas socioeconomic advantage was not. CONCLUSIONS: Invasive bladder cancer survival has decreased over the past 40 years, with the age structure of the population being a significant contributing factor. PATIENT SUMMARY: We looked at why bladder cancer survival is decreasing using a large cancer registry with information from 1977 to 2020. We found that people are now more likely to be diagnosed at an older age. Older people often live for a shorter time with bladder cancer compared to younger people. Bladder cancer survival has decreased because there are more older people with the disease than previously.

Comorbidities and their management in women with breast cancer-an Australian survey of breast cancer survivors.

PURPOSE: Breast cancer survivors experience significant burden from comorbid chronic conditions, but little is known about how well these conditions are managed. We conducted a national survey of Australian breast cancer survivors to examine the burden of chronic conditions, their impact and care alignment with the principles of chronic condition management. METHODS: A study-specific survey incorporated questions about chronic conditions using the Charlson Comorbidity Index (CCI), functional status using the Vulnerable Elders Survey (VES) and perceived quality of care for cancer and non-cancer conditions using the Patient Assessment of Care for Chronic Conditions Survey (PACIC). Members of Breast Cancer Network Australia (BCNA) were invited via email to complete the survey either online or through direct mail. RESULTS: The survey was sent to 2198 BCNA members and 177 responses were received (8.1%). Respondents were women aged 32-88 years (median 60.1 years). The majority were married (116; 67.7%) and had private insurance (137; 80.0%) and reported good to excellent health (119; 73.5%). Other health conditions were reported by 157 (88.7%), the most common being chronic pain (27.1%) and fatigue (22.0%). When asked about management of comorbidities or cancer, less than 20% were routinely asked about management goals, helped to set goals or asked about health habits. CONCLUSIONS: In this population of survivors with good health status and high rates of private insurance, comorbidities were common and their management, as well as management of breast cancer, was poorly aligned with chronic condition management principles.

Multiple Negative Fecal Immunochemical Tests Reduce Risk of Advanced Neoplasia in a Colonoscopy Surveillance Program.

BACKGROUND & AIMS: In above-average-risk individuals undergoing colonoscopy-based surveillance for colorectal cancer (CRC), screening with fecal immunochemical tests (FIT) between colonoscopies might facilitate personalization of surveillance intervals. Because a negative FIT is associated with a reduced risk for CRC, we examined the relationship between number of rounds of negative FIT and risk for advanced neoplasia in individuals undergoing surveillance colonoscopy. METHODS: We conducted a retrospective cohort study on 4021 surveillance intervals in 3369 individuals (50-74 years), who had completed a 2-sample FIT between colonoscopies, from 1 to 4 rounds at 1-2 yearly intervals, each with a negative result (<20 µg hemoglobin/g feces). Incidence of advanced neoplasia (CRC or advanced adenoma) was determined at the follow-up colonoscopy. Competing-risk regression was used to assess the association between multiple negative FIT results and the risk of advanced neoplasia within 2 years. RESULTS: The incidence of advanced neoplasia in the cohort was 9.9% and decreased with increasing numbers of rounds of negative FIT results: 11.1% after 1 negative FIT to 5.7% after 4 negative FIT. The risk of advanced neoplasia was significantly lower in participants with 3 (subdistribution hazard ratio, 0.50; 95% confidence interval, 0.24-0.97) and 4 (subdistribution hazard ratio, 0.33; 95% confidence interval, 0.15-0.73) rounds of negative FIT compared with only 1 negative FIT. CONCLUSIONS: There was a low risk of advanced neoplasia after multiple rounds of negative FIT in above-average-risk people undergoing surveillance with no neoplasia or nonadvanced adenoma at prior colonoscopy. This supports the use of interval FIT to personalize surveillance by lengthening colonoscopy intervals following multiple negative FIT results.

Twenty years of melanoma in Victoria, Queensland, and South Australia (1997 - 2016).

BACKGROUND: Given the high incidence of melanoma in Australia alongside high mortality with later stage disease, we investigated the populations and locations most at risk, to optimise public health activities in areas where intervention is most needed. This study examines trends and identifies significant prognostic factors and potential disparities in incidence, mortality and survival between population groups in Victoria, Queensland and South Australia. METHODS: The analysis includes data from the population-based cancer registries of the three states over a twenty-year period (1997-2016). Age-standardized and age-specific incidence rates were calculated, and long-term trends analysed using Joinpoint Regression. Five-year relative survival estimates for the study population were calculated using the cohort method and multivariable flexible parametric survival models were applied for each jurisdiction to calculate adjusted excess mortality hazard ratios for the key characteristics. RESULTS: There were more males with melanoma than females in all the three states. Over 60% of the cases occurred in the 40-74 years age group. Most melanomas had a Breslow thickness less than or equal to 1.0 mm. For males, Victoria and Queensland had a statistically significant increasing trend whereas in South Australia there was a decreasing trend. For females, the incidence rate trend was stable in Victoria but significantly decreasing in South Australia. In Queensland there was an increasing and statistically significant trend from 2006 to 2016. Across all three states there was a reducing incidence rate in the youngest cohort, stabilizing incidence in the 40-59-year-old age group, and increasing in the oldest cohorts. Five-year relative survival decreased with increasing age and with Breslow thickness across all three jurisdictions. Males had between 43%- 46% excess mortality compared to females in all the three states. There was higher risk with increasing age and Breslow thickness, with the largest risk among the 75 + age group and those with a Breslow thickness of > 4 mm. CONCLUSION: It is the first time that data from these three registries has been analysed together in a uniform way, covering more than half of the Australian population. This study compares the epidemiology of melanoma across three states and provides a better understanding of trends and factors affecting outcome for Australians with melanoma. While there has been some improvement in aspects of incidence and mortality, this has not been evenly achieved across Australia.

Pancreatic ductal adenocarcinoma survival in South Australia: time trends and impact of tumour location.

BACKGROUND: It is unclear how global developments in management of pancreatic ductal adenocarcinoma (PDAC) have affected survival of Australian patients. This study aimed to determine trends in survival of PDAC over the last three decades in South Australia and to compare survival based on cancer location (head and uncinate process versus body and tail). METHODS: A retrospective observational cohort study to include all cases of PDAC reported to the South Australian (state) Cancer Registry from 1990 to 2017. RESULTS: A total of 1051 patients diagnosed with PDAC between 1990 and 2017 were included. An overall increase in number of reported PDAC cases over time with more than a doubling in the crude rate from 1.73 to 3.50 per 100 000 persons between the decades 1990-1999 and 2010-2017 (P < 0.001) was noted. Overall median survival for PDAC was 7.4 months (95% confidence interval 6.8-8.0 months) and this has improved in recent decades. Overall median survival for PDAC affecting head and uncinate process of pancreas was significantly higher compared to body and tail (7.6 months versus 4.1 months; P < 0.001). CONCLUSIONS: This study from South Australia demonstrates an increased reporting of PDAC over the last three decades. Although overall survival for patients with PDAC remains low, there has been a modest improvement in recent decades. The overall survival is significantly lower for patients with PDAC involving the body and tail compared to the head and uncinate process of pancreas. Risk factors for poor survival include the male gender and advancing age (>70 years).

Late mortality in people with cancer: a population-based Australian study.

OBJECTIVES: To investigate causes of death of people with cancer alive five years after diagnosis, and to compare mortality rates for this group with those of the general population. DESIGN, SETTING, PARTICIPANTS: Retrospective cohort study; analysis of South Australian Cancer Registry data for all people diagnosed with cancer during 1990-1999 and alive five years after diagnosis, with follow-up to 31 December 2016. MAIN OUTCOME MEASURES: All-cause and cancer cause-specific mortality, by cancer diagnosis; standardised mortality ratios (study group v SA general population) by sex, age at diagnosis, follow-up period, and index cancer. RESULTS: Of 32 646 people with cancer alive five years after diagnosis, 30 309 were of European background (93%) and 16 400 were males (50%); the mean age at diagnosis was 60.3 years (SD, 15.7 years). The median follow-up time was 17 years (IQR, 11-21 years); 17 268 deaths were recorded (53% of patients; mean age, 80.6 years; SD, 11.4 years): 7845 attributed to cancer (45% of deaths) and 9423 attributed to non-cancer causes (55%). Ischaemic heart disease was the leading cause of death (2393 deaths), followed by prostate cancer (1424), cerebrovascular disease (1175), and breast cancer (1118). The overall standardised mortality ratio (adjusted for age, sex, and year of diagnosis) was 1.24 (95% CI, 1.22-1.25). The cumulative number of cardiovascular deaths exceeded that of cancer cause-specific deaths from 13 years after cancer diagnosis. CONCLUSIONS: Mortality among people with cancer who are alive at least five years after diagnosis was higher than for the general population, particularly cardiovascular disease-related mortality. Survivorship care should include early recognition and management of risk factors for cardiovascular disease.

Features associated with high-risk sessile serrated polyps at index and follow-up colonoscopy.

BACKGROUND AND AIM: Clinically significant serrated polyps are precursors of colorectal cancers, with features considered high risk including size ≥10 mm, dysplasia, and presence of synchronous conventional adenoma. While these features have been described in cohorts undergoing screening colonoscopy, there is little information regarding the prevalence and patient characteristics associated with high-risk sessile serrated polyps (SSPs) in those undergoing surveillance colonoscopy. METHODS: Polyp pathology at the index and first follow-up colonoscopy performed between 2004 and 2019 were examined in patients enrolled in a surveillance program because of an index finding of adenoma and/or SSP. Demographics and pathology features for SSP were compared between the colonoscopies. RESULTS: Of 6297 patients undergoing index colonoscopy, 2035 underwent follow-up colonoscopy after 3.3 years (interquartile range 2.1-4.8 years). The proportion with SSP decreased from 7.6% at index to 5.0% at follow-up (P < 0.001); however, the proportion of SSPs that were considered high risk was not different between the colonoscopies (62.8% vs 62.4%). Female gender was associated with the presence of high-risk SSP at index colonoscopy (odds ratio [OR] 1.62, 95% confidence interval [CI] 1.28-2.06), while age ≥75 years (OR 3.38, 95% CI 1.67-6.81) and previous high-risk SSP (OR 9.40, 95% CI 4.23-20.88) were independently associated with high-risk SSP at follow-up. CONCLUSIONS: The prevalence of SSP falls by one-third at first follow-up colonoscopy although the proportion of SSP with high-risk features remains the same. While females were more likely to have a high-risk SSP at the index colonoscopy, those at greatest risk for high-risk SSP at follow-up colonoscopy were age >75 years and an index high-risk SSP.

Continuous positive airway pressure treatment, glycemia, and diabetes risk in obstructive sleep apnea and comorbid cardiovascular disease

OBJECTIVE: Despite evidence of a relationship among obstructive sleep apnea (OSA), metabolic dysregulation, and diabetes, it is uncertain whether OSA treatment can improve metabolic parameters. We sought to determine effects of long-term continuous positive airway pressure (CPAP) treatment on glycemic control and diabetes risk in patients with cardiovascular disease (CVD) and OSA. RESEARCH DESIGN AND METHODS: Blood, medical history, and personal data were collected in a substudy of 888 participants in the Sleep Apnea cardioVascular Endpoints (SAVE) trial in which patients with OSA and stable CVD were randomized to receive CPAP plus usual care, or usual care alone. Serum glucose and glycated hemoglobin A1c (HbA1c) were measured at baseline, 6 months, and 2 and 4 years and incident diabetes diagnoses recorded. RESULTS: Median follow-up was 4.3 years. In those with preexisting diabetes (n = 274), there was no significant difference between the CPAP and usual care groups in serum glucose, HbA1c, or antidiabetic medications during follow-up. There were also no significant between-group differences in participants with prediabetes (n = 452) or new diagnoses of diabetes. Interaction testing suggested that women with diabetes did poorly in the usual care group, while their counterparts on CPAP therapy remained stable. CONCLUSIONS: Among patients with established CVD and OSA, we found no evidence that CPAP therapy over several years affects glycemic control in those with diabetes or prediabetes or diabetes risk over standard-of-care treatment. The potential differential effect according to sex deserves further investigation.

Continuous Positive Airway Pressure Treatment, Glycemia, and Diabetes Risk in Obstructive Sleep Apnea and Comorbid Cardiovascular Disease.

OBJECTIVE: Despite evidence of a relationship among obstructive sleep apnea (OSA), metabolic dysregulation, and diabetes, it is uncertain whether OSA treatment can improve metabolic parameters. We sought to determine effects of long-term continuous positive airway pressure (CPAP) treatment on glycemic control and diabetes risk in patients with cardiovascular disease (CVD) and OSA. RESEARCH DESIGN AND METHODS: Blood, medical history, and personal data were collected in a substudy of 888 participants in the Sleep Apnea cardioVascular Endpoints (SAVE) trial in which patients with OSA and stable CVD were randomized to receive CPAP plus usual care, or usual care alone. Serum glucose and glycated hemoglobin A1c (HbA1c) were measured at baseline, 6 months, and 2 and 4 years and incident diabetes diagnoses recorded. RESULTS: Median follow-up was 4.3 years. In those with preexisting diabetes (n = 274), there was no significant difference between the CPAP and usual care groups in serum glucose, HbA1c, or antidiabetic medications during follow-up. There were also no significant between-group differences in participants with prediabetes (n = 452) or new diagnoses of diabetes. Interaction testing suggested that women with diabetes did poorly in the usual care group, while their counterparts on CPAP therapy remained stable. CONCLUSIONS: Among patients with established CVD and OSA, we found no evidence that CPAP therapy over several years affects glycemic control in those with diabetes or prediabetes or diabetes risk over standard-of-care treatment. The potential differential effect according to sex deserves further investigation.

Cancer staging at diagnosis data comparisons in South Australia.

Cancer stage at diagnosis is an important gap for Australian population based cancer registries. The study aims to understand the quality and completeness of three different collections of cancer staging data. The South Australian Cancer Registry data collection for breast and colorectal cancer (CRC) cases diagnosed in 2011, was linked to Registry Derived Stage (RDS) data, pathology plus hospital metastasis codes (pathology stage), and the South Australian Clinical Cancer Registry Stage (SACCR stage). The agreement between staging systems was examined using kappa statistics. Kaplan-Meier curves and Cox regression were used to examine the difference in survival by staging methods. Among 2,530 breast and CRC cases 98.8% were stageable (n = 2,500) according to histology. Among stageable cases, 84.6% had RDS, 51.2% had pathology stage and 29.5% had SACCR stage. The kappa statistic for RDS and pathology stage was 0.930 for breast cancer and 0.973 for CRC, and 0.574 for RDS and SACCR stage for breast cancer and 0.632 for CRC. The agreement between pathology stage and SACCR stage was 0.430 for breast cancer and 0.528 for CRC. The distribution of stage was similar across staging methods, although more stage four cancers by pathology stage, and survival patterns were similar but not the same. The agreement was high between different staging systems. Pathology stage had a higher than expected stage 4 proportion. This study highlights an opportunity to collect stage information in a cost-effective manner, while collecting data that usefully represent stage at diagnosis across the population, for population based epidemiological analyses.

Effect of Native and Acetylated Dietary Resistant Starches on Intestinal Fermentative Capacity of Normal and Stunted Children in Southern India.

The health benefits of dietary amylase resistant starch (RS) arise from intestinal microbial fermentation and generation of short chain fatty acids (SCFA). We compared the intestinal fermentative capability of stunted and nonstunted ('healthy') children in southern India using two types of RS: high amylose maize starch (HAMS) and acetylated HAMS (HAMSA). Twenty children (10 stunted and 10 healthy) aged 2 to 5 years were fed biscuits containing HAMS (10 g/day) for two weeks followed by a 2-week washout and then HAMSA biscuits (10 g/day) for 2 weeks. Fecal samples were collected at 3-4 day intervals and pH and SCFA analyzed. At entry, stunted children had lower SCFA concentrations compared to healthy children. Both types of RS led to a significant decrease in fecal pH and increase in fecal acetate and propionate in both healthy and stunted children. However, while HAMS increased fecal butyrate in both groups of children, HAMSA increased butyrate in healthy but not stunted children. Furthermore, healthy children showed a significantly greater increase than stunted children in both acetate and butyrate when fed either RS. No adverse effects were reported with either RS. Stunted children have impaired capacity to ferment certain types of RS which has implications for choice of RS in formulations aimed at improving microbial function in stunted children.

Low Sensitivity of Fecal Immunochemical Tests and Blood-Based Markers of DNA Hypermethylation for Detection of Sessile Serrated Adenomas/Polyps.

BACKGROUND: Early detection and removal of precursor lesions reduce colorectal cancer morbidity and mortality. Sessile serrated adenomas/polyps (SSP) are a recognized precursor of cancer, but there are limited studies on whether current screening techniques detect this pathology. AIMS: To investigate the sensitivity of fecal immunochemical tests (FIT) and epigenetic biomarkers in blood for detection of SSP. METHODS: A prospective study offered FIT and a blood test (Colvera for methylated BCAT1 and IKZF1) to adults referred for colonoscopy. Sensitivity of FIT and the blood test were determined for four types of pathology: low-risk conventional adenoma, high-risk adenoma, SSP, and absence of neoplasia. Comparisons were made for FIT positivity at 10 and 20 µg hemoglobin (Hb)/g feces. RESULTS: One thousand eight hundred and eighty-two subjects completed FIT and underwent colonoscopy. One thousand four hundred and three were also tested for methylated BCAT1/IKZF1. The sensitivity of FIT (20 µg Hb/g feces) for SSP was 16.3%. This was lower than the sensitivity for high-risk adenomas (28.7%, p < 0.05), but no different to that for low-risk adenomas (13.1%) or no neoplasia (8.4%). A positive FIT result for SSP was not associated with demographics, morphology, concurrent pathology or intake of medications that increase bleeding risk. FIT sensitivity for SSP did not significantly increase through lowering the positivity threshold to 10 µg Hb/g feces (20.4%, p > 0.05). Sensitivity of the blood test for SSP was 8.8%, and 26.5% when combined with FIT. CONCLUSIONS: Both FIT and blood-based markers of DNA hypermethylation have low sensitivity for detection of SSP. Further development of sensitive screening tests is warranted.

Hospital volume versus outcome following oesophagectomy for cancer in Australia and New Zealand.

BACKGROUND: Volume-outcome relationships for mortality following oesophagectomy have been demonstrated in Europe and the USA, but not in Australia or New Zealand. We determined whether higher volume hospitals achieve better outcomes following oesophagectomy in Australia and New Zealand. METHODS: Administrative data for hospitals contributing data to the Health Roundtable were analysed. Hospitals performing oesophagectomy for cancer from July 2008 to June 2015 were grouped according to mean annual caseload: low (1-5), medium (6-11) and high (12+) volume. Univariate and multivariable analyses determined the impact of volume on 30-day and in-hospital mortalities, length of hospital stay and mechanical ventilation following surgery. RESULTS: A total of 2252 patients underwent oesophagectomy in 65 hospitals. Sixty-eight percent (n = 44) were low-, 26% (n = 17) were medium- and 6% (n = 4) were high-volume hospitals. Seven hundred and sixty-two (34%) procedures were performed in low-, 1042 (46%) in medium- and 448 (20%) in high-volume hospitals. Overall in-hospital mortality was 3.1% and 30-day mortality was 2.1%. In-hospital mortality was lowest in high-volume hospitals; 1.6% versus 2.6% and 4.1% for low- and medium-volume hospitals (P = 0.02). Surgery in high-volume hospitals was shorter (32 min, P = 0.001), and patients were less likely to require post-operative ventilation (16.7% versus 25.3% and 28.0%, P < 0.001), although patients requiring ventilation in high-volume hospitals were ventilated for longer. CONCLUSIONS: A volume-outcome relationship was demonstrated, with overall better performance in higher volume hospitals. Colocation of oesophagectomies to hospitals that can demonstrate appropriate caseload should be considered.

The significance of the small adenoma: a longitudinal study of surveillance colonoscopy in an Australian population.

BACKGROUND: The international guidelines for surveillance following the finding of a small tubular adenoma vary between no surveillance or colonoscopy at 5 or 10 years, whereas surveillance after an advanced adenoma is 3 years. Optimization of surveillance reduces the risk of colorectal cancer (CRC) with efficient use of colonoscopy resources. We assessed the risks of advanced colorectal neoplasia following a baseline finding of a small adenoma compared with advanced adenoma. PATIENTS AND METHODS: A retrospective audit was undertaken of patients enrolled in a CRC surveillance program, wherein regular colonoscopies and screening with faecal immunochemical test (FIT) were provided. Patients diagnosed with either small or advanced adenoma followed by at least one surveillance colonoscopy were included. Advanced adenoma included adenomas with features of villous change, size of at least 10 mm, high-grade dysplasia, three or more small tubular adenomas and traditional and sessile serrated adenomas. Subdistribution hazard ratios were calculated for advanced neoplasia (CRC or advanced adenoma). RESULTS: Overall, 378 patients (62.6±11.2 years, 57.9% male) were included, with 44.2% diagnosed with small adenoma and 55.5% with advanced adenoma at baseline. The crude cumulative incidence of advanced neoplasia at first surveillance was 13.2 and 18.5% after small and advanced adenoma (P=0.16) (at 45.9 and 35.6 months, respectively), which became significant for advanced adenoma after adjustment (subdistribution hazard ratio=2.55, 95% confidence interval=1.49-4.35, P<001). A positive FIT was the only independent predictor of advanced neoplasia after a small adenoma at baseline colonoscopy (odds ratio=5.05, 95% confidence interval=1.27-20.02, P=0.02). CONCLUSIONS: The risk of advanced neoplasia following a small adenoma was lower than that following an advanced adenoma, but was strongly predicted by a positive FIT. Reducing frequency of colonoscopy while providing regular FIT might be a more efficient use of resources for this population.

Sessile Serrated Polyps with Synchronous Conventional Adenomas Increase Risk of Future Advanced Neoplasia.

BACKGROUND: Surveillance colonoscopy guidelines following adenomas or sessile serrated adenomas/polyps (SSPs) are based on pathology features known to be associated with risk of future colorectal cancer. A synchronous conventional adenoma may increase the malignant potential of SSP, but current guidelines do not address this combination of pathologies. AIMS: The aim was to assess the risk of advanced neoplasia after SSP with or without synchronous adenoma compared to that following a conventional adenoma. METHODS: An audit was conducted on colonoscopies performed between 2000 and 2014 as part of a surveillance program. Index colonoscopy findings were classified as: low-risk SSP and high-risk SSP (size ≥ 10 mm or with cytological dysplasia) with and without synchronous adenoma; high-risk adenoma and low-risk adenoma. Risk of advanced neoplasia was determined at subsequent surveillance colonoscopies. RESULTS: In total, 2157 patients had adenoma or SSP found at index colonoscopy-low-risk adenoma (40%), high-risk adenoma (54%) and SSP (4%). Synchronous adenomas were seen with 47% of SSP. The median follow-up was 50.3 months (interquartile range 28.1-79.3). Compared to an index finding of low-risk adenoma, index findings of high-risk adenoma, as well as SSP with synchronous adenoma, were independent predictors of future advanced neoplasia (high-risk adenoma: hazard ratio (HR) = 2.04 (95% CI 1.70-2.45); high-risk SSP + adenoma HR = 3.20 (95% CI 1.31-7.82); low-risk SSP + adenoma: HR = 2.20 (95% CI 1.03-4.68)). CONCLUSIONS: Synchronous adenoma increases the risk of advanced neoplasia for SSP equivalent to that seen following high-risk adenoma. Guidelines for surveillance should take into account concurrent pathologies with SSP.

How are junior doctors managing patients with self-limiting illnesses at their first presentation? A video vignette study.

PURPOSE: To conduct a video vignette survey of medical students and doctors investigating test ordering for patients presenting with self-limiting or minor illness. METHODS: Participants were shown six video vignettes of common self-limiting illnesses and invited to devise investigation and management plans for the patients' current presentation. The number of tests ordered was compared with those recommended by an expert panel. A Theory of Planned Behaviour Questionnaire explored participants' beliefs and attitudes about ordering tests in the context of self-limiting illness. RESULTS: Participants (n=61) were recruited from across Australia. All participants ordered at least one test that was not recommended by the experts in most cases. Presentations that focused mainly on symptoms (eg, in cases with bowel habit disturbance and fatigue) resulted in more tests being ordered. A test not recommended by experts was ordered on 54.9% of occasions. With regard to attitudes to test ordering, junior doctors were strongly influenced by social norms. The number of questionable tests ordered in this survey of 366 consultations has a projected cost of $17 000. CONCLUSIONS: This study suggests that there is some evidence of questionable test ordering by these participants with significant implications for costs to the health system. Further research is needed to explore the extent and reasons for test ordering by junior doctors across a range of clinical settings.

Liver resection for colorectal cancer metastases: a comparison of outcomes over time in South Australia.

BACKGROUND: The aim of the current study was to assess outcomes following liver resection in metastatic CRC (mCRC) in South Australia across two study periods (pre-2006 versus post-2006). METHODS: The South Australian (SA) Clinical Registry for mCRC maintains data prospectively on all patients in SA with mCRC diagnosed from 01 February 2006. This data was linked with a prospectively collated database on liver resections for mCRC from 01/01/1992 to 01/02/2006. The primary end point was overall survival. RESULTS: 757 patients underwent liver resection for mCRC. Liver resection was performed on 286 patients pre-2006 and 471 patients post-2006. The median age of the study population was 62 years, and this was similar across both eras. Overall survival was significantly better in the post-2006 era (hazard ratio HR = 0.45, p = 0.001). Complications (59% pre-2006 versus 23% post-2006) and transfusion rates (34% pre-2006 versus 2% post-2006) were significantly higher in the pre-2006 era. Repeat liver resection rates were significantly higher in the post-2006 era (1% pre-2006 versus 10% post-2006). CONCLUSIONS: Outcomes following liver resection for mCRC have improved over time, with significantly better overall survival in the post-2006 era compared to pre-2006.

Uptake of a colorectal cancer screening blood test in people with elevated risk for cancer who cannot or will not complete a faecal occult blood test.

Participation rates in colorectal cancer (CRC) screening programmes using faecal occult blood tests (FOBTs) are low. Nonparticipation is commonly attributed to psychosocial factors, but some medical conditions also prevent screening. These barriers might be partially overcome if a blood test for CRC screening was available. This study determined whether people who had always declined screening by FOBT would participate if offered a blood test. An audit of registrants within a personalized CRC screening programme was undertaken to determine the reasons for regular nonparticipation in FOBT. Consistent nonparticipants (n=240) were randomly selected and invited for CRC screening with a blood test. Demographic characteristics and the reasons for prior FOBT nonparticipation were collected by means of a questionnaire. Nonparticipation in the screening programme could be classified as either behavioural (8.6%), with consistent noncompliance, or due to medical contraindications (8.5%), which included chronic rectal bleeding, being deemed unsuitable by a health professional, and needing personal assistance. Blood test uptake was 25%, with participation in the medical contraindications group greater than that in the behavioural group (43 vs. 12%, P<0.001). Reported behavioural reasons for nonparticipation in faecal immunochemical test included procrastination and dislike of the test, but these were not associated with blood test uptake (P>0.05). There is a subgroup of the community who have medical reasons for nonparticipation in CRC screening with FOBT but will participate if offered a blood test. The option of a blood test does not, however, improve uptake in those who admit to behavioural reasons for noncompliance with screening.

Changes in knowledge, beliefs, and behaviors related to fruit and vegetable consumption among Western Australian adults from 1995 to 2004.

OBJECTIVES: We monitored changes in self-reported knowledge, attitudes, and behaviors regarding fruit and vegetable consumption in Western Australia prior to and after a healthful-eating campaign. METHODS: We obtained telephone survey data from 2854 adults in Perth from Nutrition Monitoring Surveys conducted in 1995, 1998, 2001, and 2004. The "Go for 2&5" fruit and vegetable campaign was implemented from 2002 to 2005. RESULTS: We observed changes in knowledge, attitudes, and behaviors regarding fruit and vegetable intake. In 2004, respondents were more likely than in 1995 to report 2 servings of fruit (odds ratio [OR] = 3.66; 95% confidence interval [CI] = 2.85, 4.70) and 5 servings of vegetables (OR = 4.50; 95% CI = 3.49, 5.80) per day as optimal. Despite this, vegetable consumption in 2004 was less than in 1995 (rate ratio = 0.88; 95% CI = 0.82, 0.96; P = .003). Perceived adequacy of vegetable (59.3%) or fruit (34.5%) intake and insufficient time for vegetable preparation (14.3%) were the main barriers. CONCLUSIONS: Knowledge of the recommended fruit and vegetable intake increased following the Go for 2&5 campaign. Perceptions of the adequacy of current intake and time scarcity should be considered when designing nutrition interventions.