| Date | Comment |
|---|---|
| Fri Jul 30 14:48:48 1999 |
Index of comments
11.8.99 Review by Phillip Yuile 12.8.99 Response to Phillip Yuile from author 16.8.99 Response to author from Phillip Yuile 16.8.99 Review by Ray Lowenthal 16.8.99 Review by Ian Olver 17.8.99 Comments by Richard Osborne 21.8.99 Response to Ian Olver from author 21.8.99 Response to Richard Osborne from author 21.8.99 Response to Ray Lowenthal from author 21.9.99 Review by David Bell 21.9.99 Response to David Bell from author 24.9.99 Editorial comments and request for revision by Ruth Armstrong 9.11.99 Editorial decision by Ruth Armstrong Craig Bingham |
| Wed Aug 11 19:56:45 1999 | Overall interesting and I think worthy of publication, we are all
faced with these patients who are increasingly exploring non-traditional options. The response rate from the participants is diappointingly low for a small group of specialists. POINT 1: I take a little issue with statement in par 12 "indicating room for improvement in oncologist's education", it appears we are lax, I think we have more things to do with time and journal reading than keeping up to date with some of the more ethereal issues in alternative medicine. POINT 2:I like par 14 the description of alternative and complementary. I am not happy with the (par14) description relating to some psychosocial therapies showing potential benefits as being ' "unproven" can also be inappropriate.' What does 'unproven' refer to? POINT 3: One good point is made with reference that cancer pts. need to be better informed re these 'remedies' (par 16), and their lack of reproducible substance. POINT 4:I think par22 needs to be tightened up, can be shortened, some superfluous stuff there, likewise par 26. POINT 5: I am not sure par 45 adds anything to the paper, demography not that important to me. It was good to see reference to the two areas (Med and Rad Onc) and the data broken down here. Over Phillip Yuile |
| Thu Aug 12 12:46:48 1999 | Thank you for the overall positive comments - in response to:
POINT 1: We acknowledge the demands on oncologists' time and did not mean to imply that oncologists are lax in their reading - rather that, given the widespread use of these therapies among cancer patients, it may be worth including some information about non-traditional therapies in oncologists' initial training. We suggest modifying the contentious part of the sentence to read "indicating self-identified gaps in oncologists' knowledge" and adding the following clause to the end of the sentence "and suggesting a need to consider including education about these therapies in oncologists' training curricula". POINT 2: "Unproven" is another term commonly used to describe these types of therapies due to the fact that many of them have not been tested in randomised, controlled trials - as the meta-analyses referenced suggest this term may not always be appropriate, we feel it appropriate to also discount the use of this term. POINT 3: This is why we suggest there may be a need for improved training for oncologists in this area - to enable them to objectively advise their patients about non-traditional therapies they may be considering. POINT 4: We suggest modifying par 22 to read "A total of 155 medical and 118 radiation oncologists, practising in Australia, were identified via the Clinical Oncological Society of Australasia and the Royal Australasian College of Radiologists' Faculty of Radiation Oncology, representing 95% of all such Australian oncologists." We also suggest modifying par 26 to read "The surveys were mailed to the 273 identified oncologists in May and June 1997 with a written reminder to non-responders after 4 weeks and a telephone reminder after 6 weeks." POINT 5: While accepting that this paragraph may not "add" anything to the manuscript, we feel it is important to identify the survey's potential limitations and would prefer to retain it. But we would be happy to hear the other reviewers' comments in this regard. Sallie Newell |
| Mon Aug 16 00:47:10 1999 | Review of paper "Australian oncologists' knowledge and attitudes regarding non-traditional therapies used by cancer patients", by Sallie Newell and Rob W Sanson-Fisher
In this paper the authors have surveyed the knowledge and attitude of Australian oncologists to 'non-traditional' cancer therapies (otherwise often called alternative or complementary therapies). As no such survey has previously been carried out in Australia the results are of some interest. There are several difficulties. One is that the oncologists have rated their own knowledge, so we have no insight into the real extent of their knowledge of each type of treatment surveyed. Although the authors do not say so, some of the so-called 'therapies' that they asked about are so rarely used that I wonder if one or two were invented for the purpose of the survey - perhaps 'magnetotherapy' falls into that category. If it wasn't I think it should have been as use of a fictitious therapy would have been useful to assess the veracity of each individual's responses. Although the authors state several times (this is repeated unnecessarily) "the data indicate a need to improve oncologists' knowledge about these therapies and about their patients' usage of them", nowhere is this statement justified. Firstly, most oncologists seemed to think that they knew 'some' or 'lots' about the more commonly used treatments. Unless the oncologists' self-rated assessment was objectively rated there is no way of knowing whether the self-assessment was accurate or not; perhaps they did indeed know a fair bit about the therapies in question. Secondly, why do they need to know more anyway? The medical profession is nowadays committed to 'evidence-based' practice and as pointed out in the paper, evidence of effectiveness is lacking for virtually all the therapies surveyed. Oncologists need to know of the types of therapies that have the potential to harm their patients, but in fact where harm has definitely been shown, such as for coffee enemas, oncologists' knowledge seems accurate. More interesting to me is the question of why in a number of cases oncologists, presumably all with traditional training and with a commitment to scientific evidence-based practice, should have rated certain non-traditional therapies as being helpful. Why for example did 5% of oncologists think that magnetotherapy would help patients being treated with curative intent? (What is mangnetotherapy anyway? Did the oncologists who said they know about it really know?) In what way was aromatherapy thought of as helpful? - is it just the same as 'smelling the flowers' or is there a perception in the minds of some oncologists that there could be a biological effect on the patient's cancer? Were the questions asked in such a way a to enable any kind of speculation on these issues? So in order that the paper be accepted, I recommend 1) It be made clear in the Abstract and methodology that the oncologists' 'knowledge' of the various therapies was self-assessed. 2) It be stated (provided this is indeed so) that the various 'therapies' surveyed were not described or defined beyond the words given in the text and tables. 3) Para 12: I do not agree that there is 'room for improvement in oncologists' education about the non-traditional therapies' any more than there is room for improvement in oncologists' education about medieval art or pop music for that matter. As discussed above, the authors need to justify this statement. To say that the need exists because the patients are interested is still not sufficient justification in my opinion; one could say the same about gardening, football or TV soapies. There is only so much time in this world, and if oncologists judge that their time is better spent educating themselves about treatments for which good evidence exists, rather than treatments for which no good evidence exists, I would support them. The justification given in para 17 is not sufficient. It might be useful for the authors to review the oncologists' self-assessed knowledge of treatments that are known to be helpful or harmful or where there is potential for interaction with orthodox treatments. It could be reasoned that there is a need for oncologists to be aware of these, but at a glance, it seems to me that these are in fact the very treatments where the oncologists claim to have the best knowledge. 4) Para 22. In Australia haematologists care for a significant number of cancer patients, not just those with haematological malignancies. Their omission from the survey as well as that of surgeons and GPs (who also care for many cancer patients) should be noted. Presumably few respondents would have been paediatric oncologists (as there are few in Australia, and many would classify themselves as haematologists rather than oncologists) even though the authors refer several times to a previous study of non-traditional therapy use amongst paediatric patients (reference 6). This should also be noted. 5) Para 24. No definition seems to have been given for rating 'harm' so some oncologists may have taken it literally to mean direct physical harm whereas others may have interpreted the word more liberally to mean, for example, financial or psychological harm, or even harm in the sense that patients were likely to be diverted from proven treatments. This needs to be stated. The lack of definition detracts from the interpretation of the results. 6) Para 41 and Table 3. I'm not sure these are very useful or add much. Oncologists were asked to guess what proportion of their patients were using the various therapies. In some cases their guesses were similar to previous estimates and in others they were not. However patients' use of non-traditional therapies changes over time and also varies with geography and patient demographics. There is no way of knowing whether either method of estimating patients' use of the therapies was close to the truth or not as a simultaneous survey of the use of the therapies by the patients of the responding oncologists was not carried out. At most the results of this part of the survey could be described in a sentence or two with the table omitted. 7) Minor comments. There is a typographical error in reference 1. Several references do not adhere to the Journal's style as they include the issue number in brackets. The final table in the Appendix (the copy of the survey table) is wasteful of space and unnecessary. 8) Finally I note that references 14-17 are 'under editorial review', a new term to me. All are papers of the authors of the present paper. I presume this means that the papers have been returned for revision and have not yet been accepted for publication. It's impossible, then, for a reviewer to be sure of their relevance and that their inclusion in the reference list is not just a form of self-promotion. Ray Lowenthal |
| Mon Aug 16 11:01:16 1999 | Many thanks for the feed back - it is a fine paper and certainly shows interesting data, stuff we all get every day or so in dealing with patients.
Congratulations. This www feedback is quite interesting in its use of technology and rapid info. dissemination. Phillip Yuile |
| Mon Aug 16 15:54:51 1999 | The manuscript highlights that there are gaps in oncologists' knowledge about unorthodox therapies but oncologists tend to be more generally positively disposed towards psychosocial treatments.
The study was well designed in terms of covering the population required with as comprehensive a list of medical oncologists and radiation oncologists as possible. The methods are described in detail with the provision of the actual questionnaire sent. One ambiguity in the questionnaire however, is in the question about whether the therapies are considered helpful or harmful for patients treated either palliatively or curatively. It is not stated whether that is if the therapy is taken instead of, or in addition to, conventional proven treatment. This may make an enormous difference in the perceived degree of harm. The study gives useful information about patient usage of these therapies and appropriate conclusions are drawn. As far as an oncologist's knowledge goes, although gaps have been identified, it is interestingly to note that in general, the knowledge is better in therapies that are in more common usage with the gaps occurring in therapies where very few patients use them. This therefore, indicates a gap in knowledge, but not one where an education program would benefit a large number of patients, since it is only the rarer therapies, in general, where the knowledge is poor. The authors have criticised the terminology for unorthodox treatments and have used the term non traditional, suggesting that terms like alternative, unproven and complementary can be inappropriate. I would note that the TGA uses the term traditional treatments to encompass those unorthodox treatments that have been handed down through generations and therefore, denotes quite the opposite. This could create some confusion, however, I am satisfied that the authors have defined their terms at the beginning of the manuscript. The references are up-to-date and complete. The authors have quoted two other studies where this type of survey has been performed, however, the specific method of gaining information and the fact that it has been sought in the Australian population are the original aspects of this survey. The overall presentation is easy to follow and the use of tables has enhanced the flow of the text and made numerical information easy to extract. The graphics are highly necessary to the presentation with the three tables and the appendix an integral part of assessing the research. I believe the reader interest will be very high, given the reported incidence of unorthodox treatments.. IAN OLVER |
| Tue Aug 17 16:16:09 1999 | The article is well written, the survey was well designed and executed,
with a high response rate for medical specialists, and the simple results are presented clearly. The implications of the findings could have been more fully discussed in terms of the clinical and public health implications of the findings. The discussion tends to repeat the results section. It is important that potential weaknesses of the study are discussed (an important part of a scientific report). The discussion would benefit from comments on the importance of oncologist's knowledge of non-traditional treatments. The reviews deal with this quite well but "What is the duty of care?" Would increased knowledge influence patient wellbeing, quality of life, and communication/rapport their oncologist might have with their patient? Richard Osborne |
| Sat Aug 21 12:20:43 1999 | Response to Ian Olver: Another generally positive review with 2 key points that warrant discussion:
First, the reviewer queried whether the questions about therapies' potential helpfulness or harmfulness indicated whether the oncologists should consider the therapy being used instead of or in conjunction with traditional treatments. While acknowledging that such specifications would indeed be likely to affect oncologists' attitudes towards the therapies, we were keen to keep the survey instrument to one page, in order to maximise the response rate and, hence, the generalisability of the results. Given the existing literature, we were keen to explore the palliative versus curative issue and, therefore, reluctant to further complicate the survey instrument with additional subdivisions. Given the question about oncologists' perceptions of their patients' usage of non-traditional therapies, it is considered likely that most oncologists would have answered the question in terms of patients using these therapies in conjunction with traditional treatments. However, this is why we feel it important to include the actual survey instrument in the manuscript. Second, the reviewer comments that the oncologists' better knowledge of the therapies most commonly used by cancer patients suggests that additional education about non-traditional therapies may be of limited benefit. Although Table 1 does give this impression, the proportion of oncologists knowing "lots" about these therapies was much smaller than those with "some" knowledge - the proportion of oncologists knowing "lots" reached 20% for only 3 therapies. In order to overcome this problem, we would suggest splitting the "some/lots" column of Table 1 into two separate columns "lots" and "some". Sallie Newell |
| Sat Aug 21 12:21:30 1999 | Response to Richard Osbourne: While having a generally positive response to the manuscript, this reviewer made 3 key points that warrant discussion:
First, the reviewer felt that the implications of the findings should be discussed further. Second, and related to the first point, the reviewer requested further discussion of the likely consequences of increasing oncologists' knowledge in this area. In drafting the manuscript, the authors were very conscious of the journal's word restrictions, given the 3 tables we feel are necessary and to allow for the inclusion of the survey instrument in order to allow the readers to see the exact questions asked. A number of queries from the reviewers seem to confirm the need for the latter and most of the reviewers seem to agree with the usefulness of the tables in the manuscript. Therefore, as our institution is unable to pay for excess pages in the publication, there is not much scope for adding much text to the manuscript. However, we would be happy to add a paragraph to the discussion to address these issues should the manuscript be considered worthy of revision. Third, the reviewer commented that it is important to include a discussion of the study's limitations. The authors agree, as discussed in the response to Phillip Yuile. Sallie Newell |
| Sat Aug 21 12:22:31 1999 | Response to Ray Lowenthal: This review is much more scathing of the manuscript than the other 3 reviewers suggesting that there is no more need for oncologists to have knowledge about non-traditional therapies their patients may be using than about medieval art, pop music, gardening, football or TV soapies. The authors disagree with this assertion and feel that the manuscript does provide adequate justification on this issue - given the high proportion of Australian cancer patients using these therapies, their high expectations of these therapies in relation to their health outcomes, the money they are spending and the possibility of negative consequences, we feel it is important that oncologists have an objective view of these therapies and can rationally discuss the evidence, where it exists, of both associated harms and benefits with their patients - a view which appears to be shared by the other 3 reviewers and the NHMRC in the Guidelines referenced in par 17. In response to the reviewer's specific points:
1. The edit proposed in response to Phillip Yuile's review clarifies that the oncologists self-assessed their knowledge levels about these therapies. As the survey instrument clearly states this and par 24 states that "oncologists rated their levels of knowledge" - no revision is proposed for the methodology section. 2. The authors suggest adding "- no additional information was provided to the oncologists" at the end of the above referenced sentence in par 24. 3. The authors have already suggested editing par 12 (see response to Phillip Yuile's POINT 1) in a way that we feel will overcomes the contentious nature of the statement. 4. We acknowledge that medical and radiation oncologists are not the only types of clinicians who care for cancer patients and agree that further exploration of other groups' knowledge and attitudes would add to the literature in this area. However, this survey represents the first quantitative data in this area and, we believe, is quite clear about the types of clinicians involved and does not seek to generalise these findings to any other groups of clinicians caring for cancer patients. Consequently, given the limited space and the desire to add some additional discussion of the implications of these findings (see response to Richard Osbourne), no edit is proposed at this stage. 5. The authors acknowledge that no definition of "harm" was provided in the survey instrument but feel that this is made clear by the inclusion of the entire survey instrument, including the instructions, as an appendix and no edit is proposed at this stage. 6. The authors feel that par 41 and Table 3 do add useful information and that much of this would be lost by trying to remove the Table and to summarise its contents into 2 lines. As the other reviewers raised no such concerns, no edit is proposed at this stage. 7. The proposed edits to the reference section will be made. 8. The references referred to are being reviewed by the stated journal and were felt useful to include as an indication that some evidence-based summaries of this literature that may be useful to oncologists, and other clinicians caring for cancer patients, are in production - as the authors are aware of the paucity of hard evidence for clinicians in relation to non-traditional therapies and wished to indicate, for interested readers, where they may be able to obtain them in the future. If the consensus is that this is inappropriate, the authors would be happy to remove these references from the list. Sallie Newell |
| Tue Sep 21 10:39:17 1999 | This report describes the level of knowledge amongst Australian Radiation and Medical Oncologists about a range of non traditional therapies used by people with cancer. A significant proportion of the Australian Medical Oncology and Radiation Oncology specialists returned the survey and therefore the results of this report are very likely representative.
1. I have several reservations about this report however. The terminology to describe therapies of this type has always been problematical. Since psychological intervention has been shown to be helpful in the management of cancer it is now utilised by many Oncologists. Therefore psychological therapies can be regarded as being part of the orthodox medical approach to management of cancer. The Authors themselves indicate in their discussion there are now studies which show the clear benefit for psychological therapies. 2. I am not certain that their data indicate a need to improve Oncologists knowledge about many of these therapies. Most Oncologists expect to advise patients on the basis of established evidence. It seems understandable that, where there is lack of evidence, Oncologists may only have a cursory knowledge of other "therapeutic", approaches. 3. I think the first paragraph of the discussion indicates a possible bias of the Authors towards the non traditional therapies. "The more positive attitudes towards psychosocial therapies is encouraging as, at least some, proven benefits exist for these therapies." One could interpret the positive attitudes, by Oncologists, towards psychosocial therapies as a result of clear evidence for their effectiveness. In summary this report provides a good description of a range of "non traditional" therapies used in Australia and the Oncologists knowledge of such therapies. The information could probably be presented in the form of a letter. David Bell |
| Tue Sep 21 15:29:11 1999 | Response to review by David Bell.
Point 1: Concern was expressed about the labelling of psychological therapies as "non-traditional": the reviewer suggested that psychological therapies can now be regarded as part of the orthodox medical approach to management of cancer. While acknowledging the existence of studies suggesting benefits associated with psychological therapies, the authors do not feel that this automatically elevates these therapies to part of orthodox care - a belief we feel is supported by the fact that only up to 28% of patients surveyed in the studies cited reported using psychological therapies. If these therapies were viewed as part of orthodox care by cancer specialists en masse, we would expect to see higher levels of utilisation. Point 2: The reviewer queried the appropriateness of the "need to improve oncologists' knowledge" statement which has proved contentious with other reviewers: we hope the previously-suggested modifications will also be acceptable to this reviewer. Point 3: The authors concur with the reviewer - we had hoped to see more positive attitudes towards the psychological therapies because of the existence of evidence for their effectiveness not due to a biased view of these therapies. Some clarification may be necessary around this point. Final comment: The reviewer suggested that the manuscript be reduced to a letter form. The authors feel that this would result in the loss of considerable information found relevant by other reviewers but await the decision of the editors on this issue. Sallie Newell |
| Fri Sep 24 17:28:07 1999 | Editorial advice re "Australian Oncologist's knowledge and attitudes regarding non-traditional therapies used by cancer patients"
Thanks to the authors for the submission of this manuscript and to the reviewers and consultant panel members for your thoughtful comments. This manuscript has generated considerable debate (which is of interest to the committee in it's self). The manuscript and all the reviewers' comments were discussed at yesterday's editorial committee meeting. On balance ,and without any commitment to publishing the result, we have decided to offer the authors an opportunity to revise the manuscript. All the reviewers have raised important points, and we note your responses to them. We would also offer the following comments TITLE: The issue of the quality of evidence gained from self-report has been raised by several reviewers as a major limitation of the study. The term should be in the title (eg "Australian oncologist's self-reported knowledge of and attitudes to non-traditional therapies used by cancer patients"). ABSTRACT: This should also make it clear that the survey was based on self-report. Your suggestion for rewording the conclusion here seems fine. INTRODUCTION: Rather than starting with your definitions, these could be presented in a box. Thanks, everyone for your consideration of these. Is the consensus that we stick with them? METHODS: The detail currently in paragraph 22, while a bit messy, provides a clear picture of how you obtained the sample and should probably be retained RESULTS: The demographic data should be presented as it relates to the representativeness of the sample. Table three generated considerable discussion at our meeting. We agree with Professor Lowenthal that its usefulness as a comparison of what is thought to be used and what is actually used is limited. However it does draw together some interesting data. We would like it to stay as long as its limitations are discussed. DISCUSSION: As highlighted by the referees, there are some important points to include. Additional deficiencies are the fact the survey was self-report, the difficulty in comparing your responses with published studies in table 3 (as discussed by professor Lowenthal), the omission from the survey of haematologists, possible ambiguity in the questionnaire about the meaning of "harm." An important "slant" on the results is that many oncologists claimed good knowledge of the most commonly used therapies. All the referees seem to find your conclusion that knowledge is deficient and education is needed a bit superficial. Our readers may wonder along with Professor Lowenthal why they are expected to know about therapies which have not been shown to improve patient outcomes and may find themselves wondering where it all ends. A brief discussion of just how much about rare therapies Oncologists should know, and how this might affect patient outcomes is warranted. This would strengthen your conclusion. As mentioned, we consider all the referees' comments to be worth your consideration. Please address them specifically in a covering letter and highlight changes you make to the manuscript (using bold font or underlining). Please also confine the length to 2000 words. The due date for the revised manuscript is Friday November 5 1999. Please let us know if you will be unable to meet this. Thanks again everyone for your participation and, remember, the site is still open for your comments. We look forward to hearing from the authors and thank everyone once again for their contributions. Ruth Armstrong, assistant editor, MJA |
| Tue Nov 9 10:18:16 1999 | Editorial decision re "Australian Oncologists self-reported knowledge and attitudes regarding non-traditional therapies used by cancer patients"
The authors have made substantial changes to this paper in response to the referees' comments and we believe the resulting manuscript to be substantially improved. The manuscript was discussed at yesterday's editorial meeting and a decision was made to proceed with immediate publication on the MJA website and print publication in the near future. A formal letter of acceptance will follow by mail. Ruth Armstrong. Assistant editor, MJA |