How can hospitals change practice to better implement smoking cessation interventions? A systematic review.

Smoking cessation reduces the risk of death, improves recovery, and reduces the risk of hospital readmission. Evidence and policy support hospital admission as an ideal time to deliver smoking-cessation interventions. However, this is not well implemented in practice. In this systematic review, the authors summarize the literature on smoking-cessation implementation strategies and evaluate their success to guide the implementation of best-practice smoking interventions into hospital settings. The CINAHL Complete, Embase, MEDLINE Complete, and PsycInfo databases were searched using terms associated with the following topics: smoking cessation, hospitals, and implementation. In total, 14,287 original records were identified and screened, resulting in 63 eligible articles from 56 studies. Data were extracted on the study characteristics, implementation strategies, and implementation outcomes. Implementation outcomes were guided by Proctor and colleagues' framework and included acceptability, adoption, appropriateness, cost, feasibility, fidelity, penetration, and sustainability. The findings demonstrate that studies predominantly focused on the training of staff to achieve implementation. Brief implementation approaches using a small number of implementation strategies were less successful and poorly sustained compared with well resourced and multicomponent approaches. Although brief implementation approaches may be viewed as advantageous because they are less resource-intensive, their capacity to change practice in a sustained way lacks evidence. Attempts to change clinician behavior or introduce new models of care are challenging in a short time frame, and implementation efforts should be designed for long-term success. There is a need to embrace strategic, well planned implementation approaches to embed smoking-cessation interventions into hospitals and to reap and sustain the benefits for people who smoke.

Geographic variation in out-of-pocket costs for radiation oncology services.

OBJECTIVES: To examine out-of-pocket costs incurred by patients for radiation oncology services and their variation by geographic location. DESIGN: Analysis of patient-level Medical Benefits Schedule (MBS) claims data linked with data from the Sax Institute 45 and Up Study. SETTING, PARTICIPANTS: People who received Medicare-subsidised radiation oncology services in New South Wales, 2006-2017. MAIN OUTCOME MEASURE: Mean out-of-pocket costs for an episode of radiation oncology (during 90 days from start of radiotherapy planning service), by geographic location (postcode-based), overall and after excluding episodes with no out-of-pocket costs (fully bulk-billed). RESULTS: During 2006-2017, 12 724 people received 15 506 episodes of radiation oncology care in 25 postcode-defined geographic areas. The proportion of episodes for which the out-of-pocket cost was less than $1 increased from 39% in 2006 to 76% in 2017; the proportion for which out-of-pocket costs exceeded $500 declined from 43% in 2006 to 10% in 2014, before increasing to 17% in 2017. For care episodes with non-zero out-of-pocket costs, the mean amount rose from around $1186 to $1611 per episode of care during 2006-2017. The proportion of radiation oncology episodes bulk-billed exceeded 90% in nine areas; in seven areas, all with exclusively private care provision of radiation oncology, it was 21% or smaller. Within geographic areas, out-of-pocket costs for individual care episodes varied widely; in ten areas with lower bulk-billing rates, the interquartile range for costs ranged from $240 to $1857. CONCLUSION: Out-of-pocket costs are an important determinant of access to care. Although radiotherapy costs for most people are moderate, some face very high costs, and these vary markedly by location. It is important to ensure that radiation oncology services remain affordable for all people who need treatment.

Women with gynaecological cancer awaiting radiotherapy: Self-reported wellbeing, general psychological distress, symptom distress, sexual function, and supportive care needs.

OBJECTIVE: To better serve women with gynaecological cancers, we need a sound understanding of their health, wellbeing and needs. This study sought to explore these issues in a sample of Australian women before commencing curative radiotherapy. METHODS: We undertook a secondary analysis of baseline data from a supportive care trial (n = 311). Descriptive statistics were used to summarise responses to measures of wellbeing, general psychological distress, symptom distress, sexual function and vaginal changes, and supportive care needs. Pre-specified regression models were used to examine sources of variation in wellbeing and sexual function. RESULTS: Women reported lower emotional, functional and physical wellbeing than population norms (all p < 0.001). The prevalence of general psychological distress was 31% (95% CI 26-36%). Distress caused by physical symptoms was typically low. Health system and information needs comprised eight of the top ten moderate-to-high supportive care needs. Most women reported no change in interest for physical contact or sex compared to pre-diagnosis, but some sexually active women (16-24%) reported smaller vaginal size, increased dryness, and more pain on intercourse. General psychological distress was a robust marker of poorer wellbeing and sexual function. CONCLUSIONS: Before radiotherapy, a substantial minority of women with gynaecological cancers experience general psychological distress, reduced wellbeing and moderate-to-high health system and information needs. A model of comprehensive care incorporating assessment of unmet needs, general psychological distress, and sexual issues is recommended. Healthcare providers may require training to elicit and respond to a constellation of interrelated issues and access relevant services for women requiring additional support.

Developing clinical indicators for oncology: the inaugural cancer care indicator set for the Australian Council on Healthcare Standards.

INTRODUCTION: The Australian Council on Healthcare Standards (ACHS) sponsored an expert-led, consensus-driven, four-stage process, based on a modified Delphi methodology, to determine a set of clinical indicators as quality measures of cancer service provision in Australia. This was done in response to requests from institutional health care providers seeking accreditation, which were additional and complementary to the existing radiation oncology set. The steering group members comprised multidisciplinary key opinion leaders and a consumer representative. Five additional participants constituted the stakeholder group, who deliberated on the final indicator set. METHODS AND RECOMMENDATIONS: An initial meeting of the steering group scoped the high level nature of the desired set. In stage 2, 65 candidate indicators were identified by a literature review and a search of international metrics. These were ranked by survey, based on ease of data accessibility and collectability and clinical relevance. The top 27 candidates were debated by the stakeholder group and culled to a final set of 16 indicators. A user manual was created with indicators mapped to clinical codes. The indicator set was ratified by the Clinical Oncology Society of Australia and is now available for use by health care organisations participating in the ACHS Clinical Indicator Program. This inaugural cancer clinical indicator set covers high level assessment of various critical processes in cancer service provision in Australia. Regular reviews and updates will ensure usability. CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT: This is the inaugural indicator set for cancer care for use across Australia and internationally under the ACHS Clinical Indicator Program. Multidisciplinary involvement through a modified Delphi process selected indicators representing both generic and specific aspects of care across the cancer journey pathway and will provide a functional tool to compare health care delivery across multiple settings. It is anticipated that this will drive continual improvement in cancer care provision.

Development of the 'REadiness SElf-assessment (RESEA) guide' to assist low and middle-income countries with establishing safe and sustainable radiotherapy services: a pragmatic sequential mixed qualitative methods project.

BACKGROUND: Improving access to radiotherapy services in low and middle-income countries (LMICs) is challenging. Many LMICs' radiotherapy initiatives fail because of multi-faceted barriers leading to significant wastage of scarce resources. Supporting LMICs to self-assess their readiness for establishing radiotherapy services will help to improve cancer outcomes by ensuring safe, effective and sustainable evidenced-based cancer care. The aim of the study was to develop practical guidance for LMICs on self-assessing their readiness to establish safe and sustainable radiotherapy services. METHODS: The Access to Radiotherapy for Cancer treatment (ARC) Project was a pragmatic sequential mixed qualitative methods design underpinned by the World Health Organisation's 'Innovative Care for Chronic Conditions Framework' and 'Health System Building Blocks Framework for Action' conceptual frameworks. This paper reports on the process of overall data integration and meta-inference from previously published components comprising a systematic review and two-part qualitative study (semi-structured interviews and a participant validation process). The meta-inferences enabled a series of radiotherapy readiness self-assessment requirements to be generated, formalised as a REadiness SElf-Assessment (RESEA) Guide' for use by LMICs. FINDINGS: The meta-inferences identified a large number of factors that acted as facilitators and/or barriers, depending on the situation, which include: awareness and advocacy; political leadership; epidemiological data; financial resources; basic physical infrastructure; radiation safety legislative and regulatory framework; project management; and radiotherapy workforce training and education. 'Commitment', 'cooperation', 'capacity' and 'catalyst' were identified as the key domains enabling development of radiotherapy services. Across these four domains, the RESEA Guide included 37 requirements and 120 readiness questions that LMICs need to consider and answer as part of establishing a new radiotherapy service. CONCLUSIONS: The RESEA Guide provides a new resource for LMICs to self-assess their capacity to establish safe and sustainable radiotherapy services. Future evaluation of the acceptability and feasibility of the RESEA Guide is needed to inform its validity. Further work, including field study, is needed to inform further refinements. Exploratory and confirmatory factor analyses are required to reduce the data set and test the fit of the four-factor structure (commitment, cooperation, capacity and catalyst) found in the current study.

Home-based rehabilitation in inoperable non-small cell lung cancer-the patient experience.

PURPOSE: Exercise is important in lung cancer, yet most people do not meet the physical activity guidelines. The aim of this study was to characterise the views and experiences of participants with inoperable lung cancer who completed a home-based rehabilitation program. METHODS: Ninety-two participants were recruited (45 intervention group [IG], 47 usual care). Individual semi-structured interviews were conducted with participants randomised to the IG of a trial of home-based exercise, behaviour change and symptom management. Data were independently coded by two researchers, cross-checked and analysed using content analysis with a summary of arising themes. RESULTS: Of the IG (25/45), 55% were interviewed: mean (SD) age 67 (13) years; male 52%; disease stage n (%) III = 9 (36), IV = 11 (44); radical treatment intent n (%) 13 (52). The majority of participants reported program benefits, both in the physical domain (reduced sedentary time and improved strength, fitness and function) and the mental domain (motivation to keep healthy, preventing boredom). Support to self-manage symptoms was well received and many participants reported increased confidence in managing their symptoms. Exercise enablers included having expert health professional support; motivation to be stronger and better prepared for future challenges; and having an achievable and familiar program that was monitored. Treatment side-effects, pain from comorbidities and the weather were exercise barriers. For the majority of participants the use of a Fitbit™ activity tracker, text message exercise reminders and an exercise diary helped to promote adherence. CONCLUSIONS: This home-based rehabilitation program was acceptable to most participants with multiple benefits reported including improved fitness, motivation and ability to manage symptoms.

Development and testing of a guideline document to provide essential information for patient decision making regarding cancer clinical trials.

OBJECTIVE: To develop and test a guideline document to advise the content of a summarised patient information form (SPIF) regarding cancer clinical trials. METHODS: A two-phase study was undertaken to inform the development of the guideline document. In phase 1, 15 statements drawn from an international Delphi study and participant commentary were used to draft content for the guideline document. In phase 2, Delphi participants were invited to contribute to a five-step process via an online survey, to feedback on the guideline document, including the process for guideline formulation, testing application, revision, utility and clarity assessment, and completion. RESULTS: Over 73% of respondents to the online survey agreed that a sample SPIF generated by the draft guideline could support patient decision making. After the draft guideline revision, the researcher and four health professionals used the guideline to independently create a SPIF. The Flesch-Kincaid reading ease scores of the sample SPIFs were between 61.3 and 66.5, with reading levels between 7.8 and 8.8, indicating that the guideline document can assist health professionals with the generation of an understandable SPIF. The reference group members provided positive feedback on the guideline document, and an expert on plain language in healthcare information proofread the guideline document. CONCLUSION: The approach used in the study ensured the potential of the guideline document developed to enable generation of SPIFs that provide patients considering participation in a cancer clinical trial with essential and understandable information to support their decision making.

Supporting and preparing patients for radiotherapy: Patients' and radiation therapists' perspectives on their one-to-one consultations.

OBJECTIVE: Patients are often anxious and lack knowledge of radiotherapy prior to commencing treatment. Evidence-based interventions are required to reduce patient anxiety and increase patient preparation before treatment. This study is part of a larger project examining the effectiveness of an innovative preparatory intervention "RT Prepare," to reduce patient psychological distress prior to treatment for breast cancer. This study aimed to explore patients' and RTs' perceptions about the "RT Prepare" intervention and was conducted to assist with refinement of the intervention for future implementation. METHODS: Semi-structured interviews were conducted with patients and radiation therapists (RTs) to elicit their perspectives on the "RT Prepare" intervention. Thematic analysis was used to analyse the data. RESULTS: Telephone interviews were conducted with 21 patients who had received the intervention and 15 RTs who had delivered the intervention. Patients and RTs described the intervention positively and highlighted that it was beneficial for preparing patients for treatment planning and treatment. The overarching themes were communication skills; preparation; information provision and dedicated space and time. CONCLUSION: RT Prepare was well received by patients and RTs. Practice implications Based on the results of this study and our quantitative findings, implementation of the intervention would be beneficial for both patients and RTs.

Multidisciplinary home-based rehabilitation in inoperable lung cancer: a randomised controlled trial.

BACKGROUND: Lung cancer is associated with poor health-related quality of life (HRQoL) and high symptom burden. This trial aimed to assess the efficacy of home-based rehabilitation versus usual care in inoperable lung cancer. METHODS: A parallel-group, assessor-blinded, allocation-concealed, randomised controlled trial. Eligible participants were allocated (1:1) to usual care (UC) plus 8 weeks of aerobic and resistance exercise with behaviour change strategies and symptom support (intervention group (IG)) or UC alone. Assessments occurred at baseline, 9 weeks and 6 months. The primary outcome, change in between-group 6 min walk distance (6MWD), was analysed using intention-to-treat (ITT). Subsequent analyses involved modified ITT (mITT) and included participants with at least one follow-up outcome measure. Secondary outcomes included HRQoL and symptoms. RESULTS: Ninety-two participants were recruited. Characteristics of participants (UC=47, IG=45): mean (SD) age 64 (12) years; men 55%; disease stage n (%) III=35 (38) and IV=48 (52); radical treatment 46%. There were no significant between-group differences for the 6MWD (n=92) at 9 weeks (p=0.308) or 6 months (p=0.979). The mITT analyses of 6MWD between-group differences were again non-significant (mean difference (95% CI): 9 weeks: -25.4 m (-64.0 to 13.3), p=0.198 and 6 months: 41.3 m (-26.7 to 109.4), p=0.232). Significant 6-month differences, favouring the IG, were found for HRQoL (Functional Assessment of Cancer Therapy-Lung: 13.0 (3.9 to 22.1), p=0.005) and symptom severity (MD Anderson Symptom Inventory-Lung Cancer: -2.2 (-3.6 to -0.9), p=0.001). CONCLUSIONS: Home-based rehabilitation did not improve functional exercise capacity but there were improvements in patient-reported exploratory secondary outcomes measures observed at 6 months. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ACTRN12614001268639).

Assessing the cost-effectiveness of RT Prepare: A radiation therapist-delivered intervention for reducing psychological distress prior to radiotherapy.

OBJECTIVE: To determine the cost-effectiveness of RT Prepare in reducing breast cancer patients' psychological distress before treatment, compared with usual care. METHODS: RT Prepare, an intervention involving patient education and support consultations with a radiation therapist (RT), was implemented at three Australian sites (Australian New Zealand Clinical Trials Registration: ACTRN12611001000998). The primary outcome was change in psychological distress using the Hospital Anxiety and Depression Scale (HADS); secondary outcomes were changes in quality of life (QoL) and additional health service use. Costs (2015 $AU) included consultation time and training delivery. Between-group comparisons of HADS and QoL used generalised linear mixed models, and comparisons of health service use used negative binomial regression. Incremental cost-effectiveness ratios (ICERs) indicated mean costs per 1-point decrease in HADS score. Sensitivity analyses explored variation in facility size and uncertainty in intervention effectiveness. RESULTS: Among 218 controls and 189 intervention participants, the intervention significantly lowered HADS scores at treatment commencement (adjusted mean difference 1.06 points). There was no significant effect on QoL or additional service use. Mean intervention costs were AU$171 per participant (US$130, €119) mostly related to RT training (approximately AU$142 (US$108, €99). An ICER of $158 (US$120, €110) was estimated. Cost-effectiveness improved in a sensitivity analysis representing a large facility with higher patient numbers. CONCLUSION: This study provides new data on the cost-effectiveness of an RT-delivered intervention to reduce psychological distress prior to treatment, which will be useful to inform delivery of similar services. As most costs were upfront, cost-effectiveness would likely improve if implemented as standard care.

A systematic review of cancer caregiver interventions: Appraising the potential for implementation of evidence into practice.

OBJECTIVE: nformal caregivers provide substantial support for people living with cancer. Previous systematic reviews report on the efficacy of cancer caregiver interventions but not their potential to be implemented. The aim of this systematic review was to explore the potential for cancer caregiver interventions to be implemented into practice. METHODS: We searched three electronic databases to identify cancer caregiver interventions on 5 January 2018. We operationalised six implementation outcomes (acceptability, adoption, appropriateness, feasibility, fidelity, and costs) into a tool to guide data extraction. RESULTS: The search yielded 33 papers (27 papers from electronic databases and six papers from other sources) reporting on 26 studies that met review criteria. Fewer than half the studies (46%) contained evidence about the acceptability of interventions from caregivers' perspectives; only two studies (8%) included interventions developed with input from caregivers. Two studies (8%) addressed potential adoption of interventions, and no studies discussed intentions, agreement, or action to implement interventions into practice. All studies reported on intervention appropriateness by providing a rationale for the interventions. For feasibility, on average less than one-third of caregivers who were eligible to be involved consented to participate. On fidelity, whether interventions were conducted as intended was reported in 62% of studies. Cost data were reported in terms of intervention delivery, requiring a median time commitment of staff of 180 minutes to be delivered. CONCLUSIONS: Caregiver intervention studies lack components of study design and reporting that could bridge the gap between research and practice. There is enormous potential for improvements in cancer caregiver intervention study design to plan for future implementation.

A longitudinal study of four unique trajectories of psychological distress in cancer survivors after completing potentially curative treatment.

Background: Many survivors report short-term, transient psychological distress after cancer treatment. Some experience severe, worsening or persistent psychological morbidity which impairs functioning and warrants intervention. Using Bonanno's trajectories model, this study aimed to distinguish distress trajectories and to identify demographic, medical or psychosocial characteristics that differentiate those at risk of ongoing, clinically significant psychological distress. Methods: One-hundred and twenty-five cancer survivors of breast, prostate, colorectal or haematological cancers (response rate: 72%) completed measures of psychological distress (BSI-18), unmet needs (CASUN), social support (ESSI), coping styles (Mini-MAC), symptom prevalence (MSAS-SF) and benefit finding (PTGI) immediately after treatment and three and six months later. Distress and its predictors were investigated using linear mixed models. Groups based on Bonnano's trajectories were also compared on demographic, medical and psychosocial characteristics. Results: Changes in psychological distress over time were not statistically significant. Using BSI-18 clinical cut-off scores, most survivors (n = 65, 80%) were 'resilient', with stable, low distress levels. Almost one-tenth of survivors (n = 7, 9%) reported persistent, 'clinically significant' distress. Compared with the 'resilient' group, this 'chronic' group reported higher unmet needs, benefit finding, physical symptoms and poor coping styles, as well as lower social support immediately after treatment. They were also more likely to have a documented history of psychiatric illness. A 'recovered' group (n = 5, 6%) experienced high levels of distress that quickly returned to non-clinical levels and a delayed group (n = 4, 5%) reported initial low distress which worsened after treatment completion. Conclusions: Most survivors experience low distress (resilience) over time and may not require intense follow-up care. Screening for distress at the end of treatment may help to identify patients with more physical symptoms and unmet needs, less social support and higher use of maladaptive coping styles who are at risk of experiencing non-resilient trajectories of distress for further management of these symptoms.

Evaluation of an online communication skills training programme for oncology nurses working with patients from minority backgrounds.

OBJECTIVE: This study aimed to develop and assess the feasibility of an online communication skills training intervention to increase cultural competence amongst oncology nurses working with individuals from minority backgrounds. METHODS: The intervention provided examples of communication strategies using vignette-based, professionally produced videos, developed through an iterative process with input from a large multidisciplinary team. Fifty-three oncology nurses completed all three questionnaires at baseline, within 2 weeks and then 3 months after accessing the programme. RESULTS: The online intervention was well received by the majority of participants, and was endorsed as clearly presented, informative, relevant and useful by more than 90% of participants. Eighty-seven percent of participants reported increased confidence in communicating with patients via an interpreter, and 93% agreed that skills they gained would be useful in providing better patient care. Participants reported significant improvements in practice while interacting with people with limited English proficiency 2 weeks and 3 months after accessing the website (X2 = 13.66, P < 0.001). CONCLUSION: This online communication training programme can now be tested for its utility in improving patient care for oncology nurses working with patients from minority backgrounds.

RT Prepare: a radiation therapist-delivered intervention reduces psychological distress in women with breast cancer referred for radiotherapy.

BACKGROUND: The aims of this study were to determine whether a radiation therapist-led patient education intervention (RT Prepare) reduced breasts cancer patients' psychological distress (primary endpoint); anxiety, depression and concerns about radiotherapy, and increased knowledge of radiotherapy and preparedness (secondary endpoints). Patient health system usage and costs were also assessed. METHODS: A multiple-baseline study across three sites. The RT Prepare intervention comprised two consultations with a radiation therapist: prior to treatment planning and on the first day of treatment. Radiation therapists focused on providing sensory and procedural information and addressing patients' pre-treatment anxiety. Usual care data were collected prior to intervention commencement. Data collection occurred: after meeting their radiation oncologist, prior to treatment planning, first day of treatment and after treatment completion. Multilevel mixed effects regression models were used. RESULTS: In total, 218 usual care and 190 intervention patients participated. Compared with usual care, intervention participants reported lower psychological distress at treatment commencement (p = 0.01); lower concerns about radiotherapy (p < 0.01); higher patient knowledge (p < 0.001); higher preparedness for procedural concerns (p < 0.001) and higher preparedness for sensory-psychological concerns at treatment planning (p < 0.001). Mean within-trial costs per patient were estimated at $AU159 (US$120); mean ongoing costs at $AU35 (US$26). CONCLUSION: The RT Prepare intervention was effective in reducing breast cancer patients' psychological distress and preparing patients for treatment. This intervention provides an opportunity for radiation therapists to extend their role into providing patients with information and support prior to treatment to reduce psychological distress.

Building psychosocial capacity through training of front-line health professionals to provide brief therapy: lessons learned from the PROMPT study.

PURPOSE: This report describes the views of front-line health professionals who participated in a randomised controlled trial examining a model of care in which depressed cancer patients received a brief psychosocial intervention. Health professionals from four cancer centres received focused training, skill development and clinical supervision in order to deliver the intervention. METHODS: We interviewed 20 health professionals asking them about their perceptions of participation in the study and their views about more widespread implementation of this model of care. RESULTS: Participants strongly advocated for widespread implementation of this model of care; however, their ability to deliver the intervention varied depending on clinical roles and responsibilities. Many oncology nurses expressed conflict about delivering a psychosocial intervention when their clinical unit was busy. Finding a private area in which to talk was a frequent barrier in busy clinical units. Participants reported that they applied the skills and insights acquired in the study in their routine clinical work. Supervision was highly valued and was feasible to provide in clinical settings. CONCLUSION: Psychosocial care can be provided by a range of health professionals if they receive focused training and have access to supervision, but competing clinical demands are likely to limit their ability to routinely provide psychosocial care. This suggests that training should target professionals who have greater autonomy and flexibility in their work roles. TRIAL REGISTRATION NUMBER: ANZCTR1260000448044.

Identifying essential information to support patient decision-making regarding participation in cancer clinical trials: A Delphi study.

PURPOSES: This research set out to contribute to ongoing efforts to improve the quality of informed consent information provided to patients by specifically focusing on establishing consensus with regard to essential information to enhance the informed consent process. DESIGN AND METHODS: A Delphi consensus method was used to conduct three rounds of online surveys. Five groups of experts directly or indirectly involved in the informed consent process were invited to participate: patients, family members/friends, physicians, other health professionals and other key informants, including ethicists, contract research staff and pharmaceutical company staff. FINDINGS: Of 156 eligible participants, 101 participants (64.7%) completed all three rounds. In round 1, 994 information items were reported and generated into 74 statements. These were grouped under eight headings essential to the informed consent process. In rounds 2 and 3, the list was reduced to 15 statements representing consensus on essential information to be included in a summarised patient information document to support decision-making regarding trial participation. Risks and discomforts, participation requirements and trial governance were identified as important considerations. CONCLUSIONS: The 15 essential statements identified in this study could be used as components of a summarised information sheet given to potential cancer clinical trial participants, as an adjunct to the informed consent process. A robust evaluation of the impact of these statements on the quality of the informed consent process is needed.

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.

Benefits of home-based multidisciplinary exercise and supportive care in inoperable non-small cell lung cancer - protocol for a phase II randomised controlled trial.

BACKGROUND: Lung cancer is one of the most commonly diagnosed cancers, and is a leading cause of cancer mortality world-wide. Due to lack of early specific symptoms, the majority of patients present with advanced, inoperable disease and five-year relative survival across all stages of non-small cell lung cancer (NSCLC) is 14%. People with lung cancer also report higher levels of symptom distress than those with other forms of cancer. Several benefits for survival and patient reported outcomes are reported from physical activity and exercise in other tumour groups. We report the protocol for a study investigating the benefits of exercise, behaviour change and symptom self-management for patients with recently diagnosed, inoperable, NSCLC. METHODS: This multi-site, parallel-group, assessor-blinded randomised controlled trial, powered for superiority, aims to assess functional and patient-reported outcomes of a multi-disciplinary, home-based exercise and supportive care program for people commencing treatment. Ninety-two participants are being recruited from three tertiary-care hospitals in Melbourne, Australia. Following baseline testing, participants are randomised using concealed allocation, to receive either: a) 8 weeks of home-based exercise (comprising an individualised endurance and resistance exercise program and behaviour change coaching) and nurse-delivered symptom self-management intervention or b) usual care. The primary outcome is the between-group difference in the change in functional exercise capacity (six-minute walk distance) from baseline to post-program assessment. Secondary outcomes include: objective and self-reported physical activity levels, physical activity self-efficacy, behavioural regulation of motivation to exercise and resilience, muscle strength (quadriceps and grip), health-related quality of life, anxiety and depression and symptom interference. DISCUSSION: There is a lack of evidence regarding the benefit of exercise intervention for people with NSCLC, particularly in those with inoperable disease receiving treatment. This trial will contribute to evidence currently being generated in national and international trials by implementing and evaluating a home-based program including three components not yet combined in previous research, for people with inoperable NSCLC receiving active treatment and involving longer-term follow-up of outcomes. This trial is ongoing and currently recruiting. TRIAL REGISTRATION: This trial was prospectively registered on the Australian New Zealand Clinical Trials Registry ( ACTRN12614001268639 : (4/12/14).

Pancreatectomy is underused in NSW regions with low institutional surgical volumes: a population data linkage study.

OBJECTIVE: To examine differences in the proportions of people diagnosed with pancreatic cancer who underwent pancreatectomy, post-operative outcomes and 5-year survival in different New South Wales administrative health regions of residence. DESIGN, SETTING AND PARTICIPANTS: Retrospective analysis of NSW data on pancreatic cancer incidence and surgery, 2005-2013. MAIN OUTCOME MEASURES: The proportion of newly diagnosed patients with pancreatic cancer who were resected in each region; 90-day post-operative mortality; one-year post-operative survival; 5-year post-diagnosis survival. RESULTS: 14% of people diagnosed with pancreatic cancer during 2010-2013 (431 of 3064) underwent pancreatectomy, an average of 108 resections per year. After adjusting for age, sex and comorbidities, the proportion that underwent resection varied significantly between regions, ranging between 8% and 21% (P<0.001). Higher resection rates were not associated with higher post-operative 90-day mortality or lower one-year survival (unadjusted and risk-adjusted analyses). Higher resection rates were associated with higher 5-year post-diagnosis survival: the mean survival in regions with resection rates below 10% was 3.4%, compared with 7.2% in regions with rates greater than 15% (unadjusted and adjusted survival analyses; P<0.001). There was a positive association between regional resection rate and the pancreatectomy volume of hospitals during 2005-2009. An additional 32 people would be resected annually if resection rates in low rate regions were increased to the 80th percentile regional resection rate (18%). CONCLUSION: There is significant geographic variation in the proportion of people with pancreatic cancer undergoing pancreatectomy, and the 5-year survival rate is higher in regions where this proportion is higher.

A tiered multidisciplinary approach to the psychosocial care of adult cancer patients integrated into routine care: the PROMPT study (a cluster-randomised controlled trial).

PURPOSE: A stepped-wedge cluster-randomised controlled trial was conducted to evaluate the feasibility and effectiveness of a brief psychosocial intervention for depressed cancer patients, delivered by trained front-line health professionals in routine clinical care. METHODS: Nine hundred two patients were assessed across four treatment centres which were allocated in random order from control epoch to intervention epoch. Eligible patients had Hospital Anxiety and Depression Scale (HADS) scores of 8 or greater. Of eligible patients, 222 were recruited in control epoch and 247 in intervention epoch. Twenty-seven health professionals (HPs) were trained to deliver the psychosocial intervention consisting of up to four sessions, tailored to patient symptoms and distress. HPs participated in group supervision with a psychiatrist. The primary outcome, analysed by intention to treat, was depression measured with the HADS at 10 weeks after receiving the intervention. RESULTS: At 10-week follow-up, there were no significant differences in HADS score for the 181 patients in control epoch and 177 in intervention epoch (adjusted difference -1.23, 95 % CI -3.81--1.35, p = 0.35). Patients with disease progression who received the intervention experienced significant benefits in unmet practical support needs including care and support, information, and physical and daily living. CONCLUSION: A brief psychosocial intervention delivered by front-line oncology health professionals is feasible to deliver but is insufficient as a stand-alone treatment for depression in cancer patients. Psychosocial interventions should be targeted to populations most likely to experience benefit.