Cancer

Objective: To estimate the number of cancers to be diagnosed in 2025 that could be prevented solely due to changes in diet and physical activity.Design and setting: We used an Australian population-based cancer database to estimate the total number of cancers to be diagnosed in 2025, by applying published age- and sex-specific population projections to current cancer incidence rates, and multiplying the projected numbers of cancers by estimates of population-attributable fractions.Main outcome measures: Projected number of preventable cancers that would be diagnosed in 2025.Results: Our projections suggest that there will be about 170 000 Australians diagnosed with cancer in 2025. This represents an increase of about 60% on the 2007 incidence. Almost 43 000 of these cancers (low estimate, 42 295; middle, 42 657; high, 43 990) could be prevented through improvements to diet and physical activity levels, including through their impact on obesity. It is likely that this is an underestimate of the true figure. The most preventable cancer types in 2025 were estimated to be bowel cancer and female breast cancer (10 049 and 7273 preventable cases, respectively).Conclusions: About 25% of cancers, or about 43 000 cancers in 2025, can potentially be prevented through improvements in diet and physical activity. It is imperative that governments, clinicians and researchers act now if we are to reduce the significant future human and financial burden of cancer.

Peter D Baade PhD · Xingqiong Meng PhD, MD · Craig Sinclair MPPM, BEd · Philippa Youl MPH

Objective: To examine the differential in cancer survival between Indigenous and non-Indigenous people in Queensland in relation to time after diagnosis, remoteness and area-socioeconomic disadvantage.Design, setting and participants: Descriptive study of population-based data on all 150 059 Queensland residents of known Indigenous status aged 15 years and over who were diagnosed with a primary invasive cancer during 1997–2006.Main outcome measures: Hazard ratios for the categories of area-socioeconomic disadvantage, remoteness and Indigenous status, as well as conditional 5-year survival estimates.Results: Five-year survival was lower for Indigenous people diagnosed with cancer (50.3%; 95% CI, 47.8%–52.8%) compared with non-Indigenous people (61.9%; 95% CI, 61.7%–62.2%). There was no evidence that this differential varied by remoteness (P = 0.780) or area-socioeconomic disadvantage (P = 0.845). However, it did vary by time after diagnosis. In a time-varying survival model stratified by age, sex and cancer type, the 50% excess mortality in the first year (adjusted HR, 1.50; 95% CI, 1.38–1.63) reduced to near unity at 2 years after diagnosis (HR, 1.03; 95% CI, 0.78–1.35).Conclusions: After a wide disparity in cancer survival in the first 2 years after diagnosis, Indigenous patients with cancer who survive these 2 years have a similar outlook to non-Indigenous patients. Access to services and socioeconomic factors are unlikely to be the main causes of the early lower Indigenous survival, as patterns were similar across remoteness and area-socioeconomic disadvantage. There is an urgent need to identify the factors leading to poor outcomes early after diagnosis among Indigenous people with cancer.

Susanna M Cramb BAppSc(Med Sci), Grad Cert(Sc), MPH · Gail Garvey BEd, MEd · Patricia C Valery PhD, MD, MPH · John D Williamson BA(Hons), GradCert(PublicHlth), MEpi(Clin Epi) · Peter D Baade BSc, MMedSc, PhD

Is hope or optimism required for dealing with cancer? We all have hopes and dreams. For people affected by cancer, these can be even more vivid. I (L R M) have seen many people who have taught me about the power of hope and the value of asking “What are you hoping for?” I was looking forward to playing in the next concert of the Corpus Medicorum (the chamber orchestra of the Australian Doctors Orchestra), but worried about how difficult my part looked. Then I heard that our soloist only had one lung! Sue, a professional tuba player and a non-smoker, was diagnosed with an aggressive lung cancer for which the treatment was a left pneumonectomy. Her surgeon, Phillip (P A), who happened to be a talented viola player, ran the Corpus Medicorum as a hobby, and could imagine what it might be like never to be able to play music again. No one knew if Sue would be able to play her tuba after surgery. She described how Phillip had made a deal with her; “If you can play afterwards, when you are well, you will come and play a concerto with my orchestra.” The night before her surgery she was still playing at 4 am, “in case this was the last time”. The day she got home from hospital, she waited until her family had tucked her into bed and left. Then she gingerly picked up her tuba, which weighed over 10 kg, and proved to herself that she could still play a single octave scale, if not very well. Eighteen months later, after four cycles of adjuvant chemotherapy and much hard work, Sue kept her side of the bargain: she played the very difficult three-movement tuba concerto by Vaughan-Williams brilliantly, sitting alongside Phillip as principal viola. As I played my clarinet, my thoughts strayed to the bassoon player I often sat next to in the orchestra. I hoped he might be inspired to stop smoking, instead of telling me he didn’t need to because he drank green tea. Our usual much-loved conductor of the orchestra had not been able to conduct, but was hoping to be able to come to the concert, since he had chosen the music and written the program notes. At 81, he had recovered from lymphoma but myelodysplasia was now robbing him of his energy, and he required regular blood transfusions. Everyone was delighted that he made it to the concert, sat in the front row, and got up and told the audience why and how he had constructed the program. He reduced us to tears of laughter by singing a folk song from his English childhood, “Training to be a village idiot”. He died just 2 months later. Many people describe how overwhelming and frightening it is to come into the cancer treatment centre for the first time and see so many sick people. But, over time, they come to appreciate that we are all in it together, with each person having their own stories of hopes and dreams. Health professionals often feel frustrated by patients and families whose hopes appear unrealistic, particularly the refusal to contemplate that the end of their life may be near. It is important to distinguish between hope and optimism. Hope has been defined as “a process of anticipation that involved the interaction of thinking, acting, feeling and relating, and is directed towards a future fulfilment that is personally meaningful”.1 Hope can be either generalised (with no specific goal) or particular (directed towards a specific goal), for example, our conductor hoping to be well enough to attend our concert.1 In contrast, optimism refers to having a generally positive outlook on life or “viewing the glass as half full”. The distinction between optimism and hope is that of agency — exerting control over one’s future. The classic definition of dispositional optimism is having a global expectation that good things will be plentiful in the future and bad things scarce. Optimistic individuals believe that their goals can be achieved in the face of adversity and will continue to try to attain the goals, but pessimistic individuals are more likely to give up.2 We know that the psychological coping style of people diagnosed with cancer is not associated with survival or recurrence rates.3-5 But this is not what people want to hear. The study by Schofield and colleagues demonstrating that a person’s level of optimism had no impact on their survival from locally advanced lung cancer attracted hate mail from patients around the world.4 When people with metastatic colorectal cancer on a phase III clinical trial were surveyed, neither the levels of hope nor optimism had any impact on overall or progression-free survival times, but those with high depression scores had significantly worse survival times.5 Other studies have suggested that lower optimism levels are significant predictors of anxiety and depression in patients with ovarian cancer and their caregivers.6 These studies are not intended to destroy hope, as some of the hate mail suggested. We know that maintaining some hope is very important to patients with cancer, but it is reassuring to be able to tell a distressed patient that they don’t need to be positive all the time. Having a bad day or a cry will not make the cancer grow faster. Patients can also be reassured that they need not feel guilty if they are not naturally optimistic, but depression needs to be detected and treated. We also know that the level of optimism among doctors varies. Perhaps not surprisingly, a study by Jennens and colleagues, which assessed knowledge about the benefits of palliative chemotherapy for metastatic lung cancer among doctors, showed that respiratory physicians were more like to be pessimistic about outcomes with chemotherapy, and medical oncologists were more likely to be optimistic.7 Oncologists need to be aware of their own levels of dispositional optimism and try to present a balanced view. It is important to be aware that patients with unrealistic levels of optimism, such as that displayed by our bassoon player, may be more likely to participate in risky behaviours, such as continuing to smoke after cancer treatment. Some studies also report that patients and caregivers may defer palliative care or refuse “do-not-resuscitate” orders because they equate this with giving up hope. Higher levels of hope and optimism are also reported to correlate with positive psychological changes or “post-traumatic personal growth” following a diagnosis of cancer.1 A desire to maintain hope and optimism are also described as powerful motivators to participate in phase I clinical trials, even when the chance of therapeutic benefit is low. While it is essential to ascertain that patients have sufficient understanding to give informed consent to participate in a trial, it is also important to respect that, for some people, part of their expression of optimism and hope is belief in a high chance of personal benefit. One study suggests that phase I participants with high levels of treatment-specific optimism have fewer symptoms of depression at the beginning and the end of treatment.8 Part of the art of oncology is to help people maintain hope about achieving goals that are important to them but also realistic; to hope for the best-case scenario but have a plan for the worst-case scenario. The recent model suggested by Kiely and colleagues is a useful tool for helping oncologists discuss potential survival times with specific treatment regimens in advanced cancer, in a way that is realistic but maintains hope.9 They found from an analysis of randomised controlled trials in metastatic breast cancer that the worst-case scenario for survival could be simply approximated as one-quarter of the median survival time reported in the trial, and the best-case scenario as more than three to four times the median. For some, like Sue the tuba player, playing music will be a goal in itself, but there are broader benefits. It has been shown that listening to music causes dopamine release onto the nucleus accumbens, an area classically thought to mediate reward perception and addiction. A recent review found that music interventions may have beneficial effects on anxiety, pain, mood and quality of life in people with cancer, and small beneficial effects on heart rate, respiratory rate and blood pressure were identified.10 When caring for people with cancer, a willingness to be flexible, to listen and to encourage realistic hopes can be just as important and rewarding as giving the right treatment to the right person at the right time. Be prepared whenever appropriate to do things like rearrange the chemotherapy dates to fit around special events and holidays. Encourage people to go out and live life as best they can, despite their cancer. Treat people as you would hope to be treated, and you will not go far wrong.

Linda R Mileshkin MD, FRACP, MBioeth(Mon) · Phillip Antippa MB BS, FRACS · Penelope Schofield BSc(Hons), PhD, MAPS

To the Editor: Participation by patients in cancer clinical trials is low. Doctors’ reluctance to participate in clinical trials has been reported as a key barrier to recruitment.1 The Physician Orientation Profile (POP) examines doctors’ attitudes to and behaviour regarding randomised clinical trials.2 In the context of a 2010 cluster-randomised trial to assess the impact of a consumer-friendly cancer clinical trials website (http://www.australiancancertrials .gov.au), we asked medical oncologists to complete the POP and identify barriers they faced when recruiting patients to trials. The option of providing a comment on barriers identified was included. The sociodemographic characteristics of the 28 medical oncologists who participated in the trial and the barriers to recruitment reported are shown in the Box. Twenty-one doctors reported that they faced barriers when recruiting patients to clinical trials. The most common barriers identified included poor organisational infrastructure, insufficient time, slow and bureaucratic ethics approval processes, and lack of staff (medical oncologists and clinical trials coordinators). This was associated with the feeling that it is too hard to do trials. However, in contrast to studies reported during the 1990s in the United States and the United Kingdom,1,2 we found that doctors were strongly supportive of clinical trials. A high proportion gave answers consistent with the attitudes of “researchers” (practice guided by published data) rather than “clinicians” (practice guided by clinical experience). For example, if there was uncertainty about treatment, most saw this as an opportunity to do a randomised trial (26 of 28), and most believed that clinical trials were central to a medical oncologist’s practice (24 of 28). We acknowledge our small sample size and the likelihood of selection bias. However, the doctors in our study were experienced in recruiting patients to clinical trials and had firsthand knowledge of barriers to recruitment in the Australian medical system. Our findings suggest that, rather than negative attitudes of doctors, issues regarding organisational infrastructure, staffing, time and ethics approval processes are now significant barriers to recruitment of patients to cancer clinical trials. The participating doctors’ comments about the challenges of ethics and governance processes are consistent with recent publications which highlight that multisite studies are under threat because of onerous ethics review and regulatory requirements.3,4 These issues are also addressed in the first rec-ommendation of the Australian Government’s Clinical Trials Action Group report, which is “to improve the timeliness of ethics and research governance review”.5 Our results support the importance of this recommendation. Australian medical oncologists’ sociodemographic characteristics and barriers to recruiting patients to trials (n = 28), 2010 Number* Sociodemographic characteristics Mean age (years) 48 Men 20 Location New South Wales 17 Victoria 11 Practice type Mostly salaried 10 Mostly fee-for-service 9 About equal 9 Barriers to recruitment One or more barriers 21 Poor organisational infrastructure (eg, “Lack of support to employ clinical trials staff”) 11 Lack of time 9 Lack of access to clinical trials due to geographic isolation 8 Difficulty identifying eligible patients 4 Trials competing for the same patients 2 Lack of awareness about ongoing trials 2 Preference for a particular treatment arm 0 Other† 11 No barriers 7 * Data are numbers unless otherwise indicated. † Examples of comments provided for other barriers: “Hopeless, slow ethics in NSW — central ethics has not helped. Average time to get trials going exceeds average working life of trials coordinators!! It is TOO HARD to do trials. The logistics and lack of infrastructure is a major barrier” “Bureaucratic ethics and governance requirements” “Profound delays in ethics approval” “Lack of resources and man power to put more clinical trials in our treatment centre. Sometimes forgetting about ongoing trials if I am not the principal investigator and sometimes not aware of ongoing trials outside our centre” “Lack of additional medical oncologists” “Insufficient clinical trials coordinators — constant overload of staff means we have to keep halving study accrual”

Rachel F Dear · Alexandra L Barratt · Martin H N Tattersall

Whiplash: evidence base for clinical practice. Michele Sterling, Justin Kenardy. Sydney: Elsevier 2011 (xv + 197 pp, $77.25). ISBN 9780729639463. WHIPLASH is a controversial, but widely accepted, “diagnostic” term that describes a putative causal mechanism for a constellation of symptoms that are generally not underpinned by recognisable pathology. This reference book has the stated aim: “to bring together current knowledge of the whiplash condition that will allow all stakeholders involved in the management of patients with whiplash, from clinicians to policy makers, to gain greater understanding of this condition”. Whiplash research is important, as up to 50% of people with this condition do not recover fully and up to 30% remain moderately to severely disabled. The editors of this book, Michele Sterling (associate professor of physiotherapy) and Justin Kenardy (professor of psychology), are both from the University of Queensland, and have both made significant contributions to the university’s Centre of Clinical Research Excellence in Spinal Pain, Injury and Health. They are well positioned, therefore, to comment on contemporary work in their fields, particularly as considerable research concerning whiplash arises from their institution. They have also attracted contributors from a spectrum of disciplines including neurosurgery, psychology, physiotherapy, rehabilitation, epidemiology, engineering, economics and law. The book comprehensively elucidates contemporary research, particularly in the fields of physiotherapy and psychology. However, as it observes, there is little or no evidence to guide the clinician who is managing the whiplash patient. There is virtually no evidence that confirms a link between symptoms and pathology, and there is also very little established evidence-based management. The chapters on law, compensation and insurance are worthwhile reading for medical practitioners involved in the medicolegal aspects of whiplash. A series of case studies is also included. The book is recommended for scientists involved in physical and psychological rehabilitation research into whiplash. It confirms the paucity of evidence related to the whiplash construct. However, it does not assist the clinician who is interested in providing evidence-based whiplash management.

David G Vivian

Ray Moynihan explores the push for new powers and strong opposition to it If there was ever a case of market forces running ahead of regulators, it is corporatised medicine in Australia. Driven by medical entrepreneurs and merchant banks, the creation of giant health care empires has taken place with little public debate or political interest. While a new private industry is now successfully profiting from publicly funded Medicare, health authorities have so far found no meaningful mechanism to police the sector. “The business of medicine has been altered forever”, argues the former head of Medicare’s watchdog unit, “by the entry of corporatised medicine”.1 Testifying to a recent senate inquiry, Tony Webber, former Director of the Professional Services Review (PSR), said he’d like to see a revamped PSR scheme within Medicare given the power to “investigate scams and unacceptable corporate behaviour, of which I have seen significant examples”. Asked if any executive had been prosecuted, Webber told senators: “Sadly, no, because the legislation makes it very difficult to do so”.1 Responding to his concerns, the committee recommended strengthening the watchdog’s powers and government is currently considering its response. Evidence of corporate “scams”, says Webber, remains largely anecdotal and based on tip-offs which, while appearing credible, are currently unable to be followed-up. According to Webber, the problem is while companies are geared to make money, Medicare was never designed to pay the doctor and a nice corporate dividend as well — a theme he expands on elsewhere.2 One of the industry’s giants is Sonic Healthcare, owner of the Independent Practitioner Network with 140 medical centres and around 1000 GPs who produced “strong revenue growth” last year, contributing to Sonic’s overall profit of $295 million.3 The other giant is Primary Health Care Limited, running almost 90 centres, also contracting 1000 doctors, worth around $1.5 billion, and with profits of $80 million.4 Another player is Healthscope, bought recently by a consortium of global private equity firms. All three are “vertically integrated”, with medical centres, pathology laboratories and imaging facilities. There is no suggestion that these, or other particular corporations, or people associated with them, engage in or encourage any form of inappropriate behaviour. The man known for pioneering corporatisation of health care in Australia is Edmund Bateman, managing director of Primary Health Care Limited. The company describes itself as the “most profitable in this field” with a “formula” offering value to doctors and patients.4 In an extended interview with me recently, Bateman strongly rejected the need for enhanced watchdog powers, saying it was “based on the assumption that the corporation is responsible for the behaviour of the doctor”, which was “out of touch” with the reality. He said there’s also an assumption of “improper pressure” on doctors, but it doesn’t exist. “I can’t tell them what to do”, he told me, “if there is any pressure, it’s to practise better medicine”. While stressing that doctors signing contracts with Primary Health Care Limited retained clinical autonomy, in general, they also “undertake to support our services, where clinically appropriate” he said, adding doctors “tend to support the pathology in the building, out of convenience”. The idea of forcing corporations to contribute to paying the fines of doctors found to have practised inappropriately is also opposed by Bateman: “it’s human nature for people to try and blame other parties”, he says, “professionals in particular are responsible for their own behaviour”. Arguing it’s not “proper process”, he suggests that the entire PSR Scheme should be abandoned and any action against doctors happen via “normal legal process”. Asked about his own use of courts to take action against doctors contracted to his companies, and a newspaper report that there had been dozens of cases against practitioners in the past decade,5 Bateman declined to confirm a figure, saying that of the 1000 contracts with doctors only a “very small minority” ended in litigation, and that he is suing the newspaper involved. Questioned about suggestions that his centres had created and billed for “care plans” for patients who regularly saw doctors outside, he said that “sounds like sour grapes from someone who should have provided one before this”. Other corporate chiefs contacted declined to comment. In my view, one way to independently assess competing claims about corporate medicine might be to compare profiles of doctors working inside and outside corporate structures. While complex, with confounding factors, a sophisticated analysis could cast much-needed light here and build academic expertise in the field. As to recommendations for new powers to “pursue abuse” of the system,1 the government’s response is pending. Perhaps it may also be timely to reassess just how well the private-for-profit corporate structure sits with the spirit of a publicly funded universal health insurance scheme.

Ray Moynihan BA

Yes. Public health adviser David Roder and Cancer Council Australia CEO Ian Olver believe the reduction in breast cancer mortality in Australia reflects both treatment and screening effects All screening programs should be assessed for their benefits and risks, including the extent of overdiagnosis. Recently, Burton and colleagues concluded that almost 60% of the Australian decline in breast cancer mortality since 1991 could not be due to BreastScreen Australia (the free national mammographic program), attributing most of the decline to adjuvant hormonal and chemotherapy.1 Questions around attribution are not new. There has been no formal modelling in Australia, but modelling funded by the National Cancer Institute in the United States suggested that about half the US breast cancer mortality reduction may be due to adjuvant therapy and about half to screening.2 Age-standardised breast cancer mortality rates have decreased by about 29% among Australian women since the 1989–1991 period, when organised mammography screening (now known as BreastScreen) began.3 Compared with a linear projection of mortality increases in the 1980s, the observed rate in 2007 was about 38% lower.3 Observations on women outside the screening age range show that factors other than screening would have contributed to this decline, but there is also evidence for an important BreastScreen effect.3 Three evaluations of mammography screening of Australian women aged 50–69 years, including the formal BreastScreen Australia Evaluation Plan, indicated reductions in breast cancer mortality of between 30% and 47% from screening.3 This range is broadly consistent with trial evidence where a reduction of around 35% was estimated by an expert working group of the International Agency for Research on Cancer (IARC).4 A 25% reduction in breast cancer was estimated by Australian researchers from a meta-analysis of trial data for all ages.5 Collective results of 35 studies in other countries are similar to the IARC’s 35% reduction estimate,3,4 although individual study results varied from little or no benefit to reductions of up to 76%.3 With present participation rates in Australia’s BreastScreen program, a 35% reduction in breast cancer mortality in participants would correspond with an estimated 270 fewer breast cancer deaths a year in all Australian women aged 55–74 years. (Note that this allows for a time lag of 5 years in deaths.) Breast cancer incidence rates rose in Australia following the introduction of BreastScreen.3 The extent to which this reflected lead-time effects of screening, changes in pathology and other diagnostic practices, overdiagnosis, and real increases due to changes in underlying risk factors (eg, reproductive behaviour, body weight, alcohol consumption and use of hormone replacement therapy) is unknown. Increases in incidence were already occurring in the 1980s before BreastScreen introduction,3 but the contributions of increased use of private mammography and changes in risk factors during that period are not known. The increase in breast cancer mortality rates in the 1980s is suggestive of real increases in underlying incidence.3 There is concern that screening may result in detection of cancers that would never have caused symptoms or death in a woman’s lifetime (ie, overdiagnosis).3 There is no consensus on levels of overdiagnosis, with estimates worldwide varying from close to zero to over 30% of diagnosed cancers, irrespective of whether in-situ lesions were included.3 The estimates vary so widely that interpretation is difficult. Research is needed to better define levels of overdiagnosis and, ideally, to develop more effective means of determining at diagnosis the potential for screen-detected and other breast cancers to progress. In summary, it is likely that the reduction in breast cancer mortality in Australia reflects both treatment and screening effects. The relative contribution of each to the overall reduction is not clear, although there is evidence that both would be contributing substantially. Women should be informed of both the risks and the benefits of screening, including the uncertainty around overdiagnosis. However, present screening participation levels of 50–69-year-olds in BreastScreen would be consistent with a significant annual reduction in breast cancer mortality. Levels of overdiagnosis are uncertain and require better definition. Means of better predicting the likelihood of progression of untreated in-situ lesions and early invasive breast cancers to advanced disease are needed, and this need is likely to increase as more sensitive screening and diagnostic technologies are developed.

David M Roder PhD · Ian N Olver MD, PhD, FRACP

No. Breast cancer researchers Robin Bell and Robert Burton believe that screening can result in overdiagnosis Screening mammography undoubtedly saves lives. Since 1991, when Australia’s free national mammographic screening program (BreastScreen Australia) began, there has been a 29% reduction in breast cancer-specific mortality. However, our analysis of age-stratified data indicates that BreastScreen does not account for most of this mortality reduction.1 Furthermore, it is now recognised that the balance between the benefits and harms of screening has become increasingly unfavourable. Women should be given a balanced explanation of what BreastScreen offers them. Our study analysed age-specific trends in breast cancer incidence, mortality and BreastScreen participation by Australian women aged 40–79 years since 1991.1 We found that the participation rates and relative mortality declines were the opposite of what the randomised controlled trials (RCTs) of mammographic screening had predicted. Women aged 40–49 years, who had the lowest BreastScreen participation (about 20%), had the largest mortality reduction (43.6%; 95% CI, 34.8%–51.2%). Women aged 60–69 years, who had the highest BreastScreen participation (about 60%), had the smallest mortality reduction (19.1%; 95% CI, 10.5%–26.9%). We also analysed the proportions of the declines in absolute breast cancer-specific mortality from 1991 to 2007 in two parts (before and after 1999–2000), to identify periods before and after any effect of BreastScreen on mortality might have been expected. We found that only about a third of the reduction in mortality in the age group invited for screening (50–69 years) occurred after 1999–2000.1 We have calculated the contribution that adjuvant endocrine therapy and chemotherapy could have made to the reduction in breast cancer mortality in Australia since 1991. Australia is unique in having six datasets from population-based breast cancer treatment surveys between 1986 and 1999. These document the stage at diagnosis and adjuvant treatment received for early breast cancer for different samples of Australian women. Based on a 10–15-year follow-up of their overviews of RCTs of adjuvant therapy in early breast cancer between 1985 and 2000, the Early Breast Cancer Trialists Collaborative Group (EBCTCG) concluded that appropriate use of anthracycline-based chemotherapy followed by tamoxifen for oestrogen-receptor-positive disease would result in annual breast cancer mortality reductions of 57% for oestrogen-receptor-positive women < 50 years of age and 45% for those aged 50–69 years.2 Our analysis, using 1999 Victorian survey results and the EBCTCG overview, found that breast cancer mortality reductions in Australian women in 1999 from adjuvant endocrine therapy and chemotherapy could have been up to 38% for women aged 40–49 years, and up to 24% for women aged ≥ 50 years.1 Therefore, adjuvant therapy had the potential to produce most of the 29% reduction in breast cancer mortality in Australia since 1991. In theory, screening for an asymptomatic earlier stage of a disease that is more effectively treated with available therapies than symptomatic disease will produce less morbidity and mortality, but screening can result in overdiagnosis. Overdiagnosed breast cancers are those detected by screening mammography that would not have become symptomatic in the woman’s lifetime. Overdiagnosis by mammographic screening is most accurately estimated from the RCTs by comparing the increased numbers of breast cancers diagnosed in women invited to undergo screening compared with those not invited. A recent Cochrane systematic review of the RCTs puts the estimate at 30%.3 An estimate from incidence trends in New South Wales indicated that 30%–40% of invasive breast cancers were overdiagnosed in 1999–2001.4 The benefits and harms of mammographic screening are measured in terms of the ratio of lives saved to cases overdiagnosed. Using the RCT data, the 2011 Cochrane review determined that, with 30% overdiagnosis and a relative mortality reduction of 15%, “for every 2000 women invited for screening throughout 10 years, one will have her life prolonged. In addition, 10 healthy women, who would not have been diagnosed if there had not been screening, will be diagnosed as breast cancer patients and treated unnecessarily”.3 As the outcome of treatment for both symptomatic and asymptomatic disease improves, the impact of screening diminishes and the balance of benefits to harms will become less favourable. This has serious implications for health policymakers. We believe it is time for women to be presented with a more balanced view about the benefits and harms of breast screening. Screening programs are currently undergoing review in the United Kingdom, and one of the first commitments is to a new process of developing written information for the public that will synthesise information on benefits and harms. There has been an assurance that the leaflet about breast cancer screening will be among the first to be revised.5

Robin J Bell PhD, MPH, FAFPHM · Robert C Burton MD, PhD, FRACS

Supply must meet demand to maintain our high standards of cancer care Recent years have witnessed significant progress in cancer treatment, with improved outcomes,1 treatment options, emergence of survivorship care, and acceptance of multidisciplinary care as the optimal care delivery method.2 All Australian states have cancer plans, and considerable funding has been committed to cancer control by state and federal governments. While cancer outcomes in Australia are excellent by world standards, cancer care providers and consumers are concerned about the ability of the oncology workforce to meet the growing demand, and the effect that shortages may have on the quality of care. The number of new cases of cancer continues to increase by about 3% per year because of increased population, improved longevity and increased detection rates. Over a decade, the increase amounts to nearly 40%.1 The expansion of cancer services has barely kept pace with the increased number of cases, and the number of training positions, while highly in demand, is not sufficient to address the need.3 This concern is illustrated by a recent major federal government investment into rural cancer centres of $560 million.4 The funding is subject to a partnership agreement with the states to ensure an adequate workforce (as well as other recurring costs) to deliver care in rural centres. With 20 facilities to be created or expanded with federal funding, and others developed with state support (10 additional facilities in South Australia alone), there can be only two potential strategies for workforce supply. One is to create new positions (unlikely to be successful, given the national and international shortages in the cancer workforce and no specific commitment of additional funding for that purpose); the other is to redistribute the existing workforce and optimise work practices to manage additional demands. It seems prudent to consider these possibilities in some depth, and we have done so using information from the recent workforce survey of the Medical Oncology Group of Australia (MOGA).5 Medical oncology is a key element of multidisciplinary cancer care, and is thus fundamental to services in the proposed rural expansion. It is estimated that about half of cancers require treatment with at least one course of systemic therapy.6 Medical oncologists (MOs) frequently supervise chemotherapy, targeted therapies, treatment with biological agents and hormonal therapy. They may be responsible for care coordination and provide supportive, palliative and follow-up care. The MOGA survey demonstrates that currently in Australia there is a significant shortage and uneven distribution of MOs that is unlikely to be addressed by the increase in training positions. Of even more concern is that the estimated chemotherapy utilisation rate (the proportion of new patients with cancer who receive chemotherapy at least once during their illness) appears to be less than half the recommended rate.5 There is no indication that MOs turn patients away (although the subject was not specifically covered in the survey), and it is likely that the low chemotherapy utilisation rate may reflect limited access to MOs or limited awareness about the value of medical oncological treatment among referring doctors. Increasing engagement of MOs with other doctors and development of rural centres may help solve these problems. But the concern remains that with the existing medical oncology workforce, we simply do not have the capacity to increase the chemotherapy utilisation rate. The federal government investment in infrastructure for rural cancer centres is one example of the challenges for the cancer workforce in general. The current workforce of 234 full-time equivalent (FTE) MOs will need to absorb the work demands of the additional 20 rural facilities. Even allowing an average of 0.5 FTE MOs per site, this would require an increase of 10 FTE MOs, which seems hard to achieve, given that 29 FTE MO positions are currently unfilled. Some patients who would be seen in the rural centres are currently seen in metropolitan facilities, so there will be some shift in workload, but there will also be a need to allow time to travel, especially in states where the population density is such that there is just not enough work for a resident MO. There will also be a cost associated with taking an MO out of the existing facility to provide care elsewhere. We do not claim that these figures are precise, but they illustrate the calculations that may be required and are yet to be presented. We hope that raising these issues may serve as a call to action, because without thoughtful strategies to increase the oncology workforce, the investment of $560 million may not reach its full potential. So what can be done? We argue that quite a lot can be achieved. The medical oncology profession is committed to promoting best practice and monitoring workload and current and future demand to deliver care with the highest quality and safety, as close as practicable to patients’ homes. MOs are open to innovation and welcome nurse practitioners, physician assistants and other innovative health care delivery strategies, including shared-care models, role redesigns and “e-health” solutions that can improve efficiency and access to care. Every effort should be made to reduce inefficient and unnecessary care; for example, use of chemotherapy when palliative care may be more appropriate, and MO management of patients who may be more appropriately followed up in general practices. The solutions need to be feasible, and consistent across the public and private (which currently has less access to innovative models of care delivery) sectors. The federal government has established two agencies with significant roles to play: Cancer Australia and Health Workforce Australia. These agencies and the profession must jointly address the challenges ahead in order to solve problems across jurisdictions — across state and federal boundaries, rural and metropolitan areas, the public and private sectors, government and training colleges and across professions. Just as we recognise that clinical care can best be delivered in a multidisciplinary setting, we need to start planning cancer care in the multidisciplinary setting. We know that work shortages described in medical oncology are similar to those in other disciplines, and addressing shortages in one area in isolation will not solve the problem; solutions must encompass the entire spectrum of cancer care professionals. Australia is unique internationally in having a strong professional multidisciplinary cancer organisation (the Clinical Oncological Society of Australia) that can engage cancer providers across disciplines. Now we need the jurisdictions to work with Cancer Australia and Health Workforce Australia in conjunction with the professional groups and consumers. We have seen the benefits of this approach already, in radiation oncology. The Radiation Oncology Reform Implementation Committee, under the auspices of the Australian Health Ministers’ Advisory Council, has driven significant improvements in delivery and staffing in Australia, and was another driving force for the regional cancer centre initiative. We need to apply similar processes to delivery of systemic anticancer therapies. We need to better define the problem. The MOGA survey is a good start, but points out one serious limitation: without national investment into robust data collection systems, we will not be able to plan effectively or monitor outcomes of interventions. The MOGA survey calls for a national cancer workforce plan that can provide projections and recommendations for the future. It takes 13 years to train an MO from the time of entry into medical school. To plan for the 40% growth in cancer incidence over the next 10 years, we need to invest in new training positions today, focusing not only on numbers of places but also on creating systems allowing people to work more efficiently and flexibly, so we not only attract them to the profession but retain them at peak performance. We need to agree as a society what standards of care we aspire to and what standards we can realistically deliver. How many patients can we reasonably expect an MO to see without risking burnout or dangerous errors occurring? We need to engage consumers in some difficult conversations on how we can provide the best care, not in the ideal setting, but in the reality of our limited (human) resources. Australia has one of the highest standards of cancer care in the world, but we can do even better with appropriate staffing, quality and distribution of our cancer care workforce. It is time to come together to start addressing the looming shortages before it is too late.

Bogda Koczwara MB BS, FRACP, MBioethics · Michael B Barton OAM, MB BS, FRANZCR · Euan T Walpole MB BS, FRACP · Peter Grimison MB BS(Hons), PhD, FRACP · Prunella L Blinman BMed, FRACP · Sally Crossing AM, BEc · Kay Francis BA(Hons), MA(Hons), MBA

To the Editor: The median age of Australian patients at first diagnosis of cancer is 67.8 years.1 In advanced, incurable cancer, goals of treatment include symptom control for all patients and prolongation of survival by weeks to months in a subgroup. In older people, treatment decisions can be complicated by comorbidities, polypharmacy, frailty and cognitive impairment. Few studies have investigated older patients’ information needs and preferences for involvement in decisions about their care.2,3 We performed an exploratory study to investigate whether the health status of older cancer patients predicted their information needs, decision preferences and their oncologists’ treatment recommendations. Concordance between patients’ stated preferences and the perceptions of their oncologists was also measured. Fifty outpatients with advanced lung (n = 30) or bowel (n = 20) cancer, with a mean age of 66.9 years (range, 51–91 years) participated. Fourteen patients (28%) were older than 70 years and 80% were diagnosed with advanced cancer within the previous 4 months. Patients’ health status was measured using the Vulnerable Elders Survey (VES) 13, a validated questionnaire used to identify older persons at risk of health decline (indicated by scores of ≥ 3).4 Role preferences were elicited using the Control Preferences Scale.5 Thirteen patients (26%) had VES 13 scores of ≥ 3. Of these, five (38%) were over 70 years. Twenty-six of 49 patients (53%) wanted a passive role in decision making, and 29 of 50 patients (58%) wanted prognostic information. Age and VES 13 scores did not predict patients’ role preferences or desire for prognostic information. Oncologists were less likely to recommend chemotherapy for patients over 70 years (25% v 75%, P = 0.04) or for those who had VES 13 scores of 3 or above (20% v 80%, P = 0.02). Concordance between patients’ participation preferences and oncologist perceptions was 54%. Until there is more evidence from larger studies of patient preferences, oncologists should ask patients their preferences about decision making and prognostic information. Patients with advanced cancer, by characteristic and preference Characteristic Prefer non-passive decision control* Prefer prognostic information Total patients (n = 50) 23 29 Age 50–60 years 6 7 Age 61–70 years 11 14 Age 71–80 years 5 5 Age > 80 years 1 3 Male 10 18 Female 13 11 Born in Australia 15 14 Born outside Australia 8 15 Bowel cancer 13 19 Lung cancer 10 10 0 comorbidities† 3 5 1 comorbidity† 3 5 2 comorbidities† 4 7 ≥ 3 comorbidities† 12 12 0 concomitant medications‡ 1 4 1 concomitant medication‡ 2 3 2 concomitant medications‡ 7 5 ≥ 3 concomitant medications‡ 13 15 Lives alone 8 9 Lives with someone 15 20 Lives in aged care facility 0 0 ECOG PS = 0–1 20 24 ECOG PS = 2–3 2 4 Married 9 13 Not married 14 16 Primary education§ 3 5 Secondary education§ 14 14 Tertiary education§ 5 10 VES 13 score = 0–2¶ 17 19 VES 13 score = > 3¶ 6 10 ECOG PS = Eastern Cooperative Oncology Group performance status; higher score = poorer status. VES = Vulnerable Elders Survey. * Total in passive and non-passive categories was 49 (one patient gave no preference). † Missing data for one patient. ‡ Missing data for three patients. § Missing data for two patients. ¶ VES 13 scores range from 0–10; scores > 3 indicate vulnerability to health decline.

Lakshmi P Venkateswaran · Phyllis N Butow · Jesse Jansen · Nicholas R C Wilcken · Mark K Wong · Rina Hui · George Szonyi · Val J Gebski · Vasi Naganathan · Lisa G Horvath · Martin H N Tattersall

Objective: To determine current and projected supply, demand and shortfall of medical oncologists (MOs) and the Australian chemotherapy utilisation rate.Design, setting and participants: A 2009 cross-sectional observational study of Australian adult medical oncology practice work patterns.Instrument: Electronic or paper self-administered questionnaire.Main outcome measures: The 2009 and projected (2014) supply, demand and shortfall of full-time equivalent (FTE) MOs, and the chemotherapy utilisation rate.Results: 476 medical oncology positions comprising 234 FTE MOs were identified. Of the 150 medical oncology practices, 117 (78%) were in metropolitan locations and 33 (22%) were in rural locations. The average number of new patients seen per FTE MO was 270 patients (ranging by state from 191 to 343). The demand for FTE MOs was estimated at 326 to 391 in 2009 and 361 to 432 in 2014. The shortfall of FTE MOs was estimated at 92 to 157 in 2009 and 84 to 156 in 2014. The chemotherapy utilisation rate was 19%.Conclusions: The current shortage of MOs is expected to persist in the future. National strategies are needed to increase the capacity of the medical oncology workforce and the chemotherapy utilisation rate.

Prunella L Blinman BMed, FRACP · Peter Grimison MPH, PhD, FRACP · Michael B Barton OAM, MD, FRANZCR · Sally Crossing AM, BEc · Euan T Walpole MB BS, FRACP · Nora Wong BCom/BSocSc · Kay Francis BA(Hons), MA(Hons), MBA · Bogda Koczwara MB BS, FRACP, MBioethics

This is the first reported Australian case of synovial sarcoma of the pharynx. A 29-year-old man had a large hypopharyngeal mass excised and received radiotherapy and chemotherapy. No recurrence was seen 12 months later. Clinical recordA 29-year-old man presented to the emergency department with stridor and a background of progressive globus sensation, loud snoring and worsening dysphagia over 2 years. He had not suffered weight loss, and past medical history was otherwise unremarkable. Flexible endoscopy examination revealed a well circumscribed, encapsulated tumour arising from the left lower lateral wall of the oropharynx and hypopharynx, and from the left arytenoid on its posterior aspect (Box 1). Computed tomography (CT) scanning revealed a 3 × 4.1 cm soft tissue mass arising from the left pharyngeal wall just inferior to the tonsillar fossa (Box 2). Endoscopic laser resection (microlaryngoscopy) was carried out with several scopes, including a bivalved speculum and a Boyle–Davis gag to gain full exposure. The capsule was broken at its deep aspect; however, macroscopic clearance was achieved with dissection down to healthy muscle. The patient made an uneventful recovery and was discharged on Day 3. Histopathological analysis revealed a well circumscribed tumour that measured 8 × 4 × 3 cm and was composed of relatively uniform spindle cells showing frequent mitotic activity. The tumour showed focal necrosis and focal calcification. The posterior surface was raw, suggesting incomplete margins. The cells stained positively for vimentin and CD99, and occasional cells stained positively for cytokeratin AE1/AE3 and epithelial membrane antigen (EMA). Fluorescent in-situ hybridisation (FISH) identified an extra copy of the 5′SS18 signal, suggesting the presence of an unbalanced translocation of the SS18 gene at the 18q11 region. Based on the histological features and FISH results, a diagnosis of monophasic synovial sarcoma was made. Repeat microlaryngoscopy was performed and biopsies of the tumour bed were taken, and histopathological analysis revealed no evidence of residual tumour. Positron emission tomography (PET) and CT staging scans revealed no evidence of regional or metastatic disease. Postoperative radiotherapy was administered to the surgical bed, delivering 60 Gy in 30 fractions over 6 weeks, with bilateral prophylactic nodal irradiation to 50 Gy. After discussion at the multidisciplinary clinic, the patient was administered four cycles of doxorubicin and ifosfamide chemotherapy. Twelve months after the initial diagnosis, there was no evidence of recurrence on endoscopy or PET scan. DiscussionSynovial sarcomas are high-grade soft tissue sarcomas that are thought to arise from pluripotential mesenchymal stem cells.1,2 They account for 10% of all soft tissue sarcomas, and less than 10% occur in the head and neck region.2,3 Since the first case of head and neck synovial sarcoma was described in 1954, there have been fewer than 200 cases reported in the world literature.4 Published cases of synovial sarcoma of the pharynx are rare,5-9 and to our knowledge, this is the first reported case in Australia. There is a male predominance, with a male-to-female ratio of 3 : 2, and although synovial sarcomas can occur at any age, they are most commonly found in patients aged between 25 and 35 years.5,9,10 The neck is the most commonly reported site for primary synovial sarcoma within the head and neck, followed by the upper aerodigestive tract.4 The most typical presentation is a painless mass;2 however, pain, odynophagia, otalgia, bleeding and, in rare cases, pulmonary metastases have also been described. Our patient presented with non-specific upper aerodigestive symptoms, which highlights the importance of a thorough clinical examination. Case reports of pharyngeal synovial sarcomas have found that most patients present within 3 months of the onset of symptoms.5-7 This is in contrast with our patient, who presented after years of loud snoring, progressive globus sensation and eventually stridor. This resulted in a very large tumour almost completely occluding the airway. There are two types of synovial sarcoma, monophasic and biphasic.11 Two-thirds are biphasic, comprising a mixture of elongated basophilic spindle cells and glandular structures made of columnar epithelial cells. Monophasic forms are composed solely of spindle cells or, very rarely, epithelial cells. Monophasic forms are easier to misdiagnose as fibrosarcomas or malignant peripheral nerve sheath tumours, and immunohistochemistry that shows positive reactions for keratin and EMA and FISH can help differentiate these from other sarcomas.1,11 Work-up should include PET and CT scanning of the head, neck and chest to determine the extent of local disease and to search for metastases. The treatment of choice is complete surgical excision with clear margins and adjuvant radiotherapy.4,12-14 For soft tissue sarcomas in general, clear margins have been associated with reduced recurrence and improved survival.12,14 The issue of margin status is particularly important for pharyngeal disease, where attaining wide margins is technically more difficult, and postoperative function for speech and swallowing are important considerations. Postoperative radiotherapy is increasingly recommended as it is associated with reduced local recurrence;4,13,14 however, a survival advantage is yet to be demonstrated. Treatment of the cervical lymph nodes in patients with nodal disease should comprise therapeutic lymph node dissection. There have been no studies on the roles of elective lymph node dissection and prophylactic regional radiotherapy in node-negative patients, and this is an area for future research. The role of neoadjuvant or adjuvant chemotherapy for synovial sarcoma is inconclusive. In a meta-analysis of 14 randomised controlled trials,15 doxorubicin-based chemotherapy was associated with improved recurrence-free survival but not overall survival. A more recent study on ifosfamide-based chemotherapy for synovial sarcomas of the extremities showed an improvement in disease-specific survival.16 As always, the benefits of chemotherapy need to be weighed against the potential significant side effects. Synovial sarcoma is an aggressive disease with a 5-year survival rate of less than 75%.17 There are conflicting conclusions regarding survival among patients with head and neck disease, with some authors reporting a better prognosis for synovial sarcomas of the head and neck compared with the extremities,18 and others reporting a worse prognosis.19 Favourable prognostic indicators include younger age (< 20 years), monophasic subtype, wide excision and, most significantly, smaller tumour size (< 5 cm).3,4 Disease recurrence is a significant problem, with up to 45% of patients with head and neck synovial sarcoma developing a local recurrence and 33% developing distant metastatic disease.4 Further, recurrences occur late, with a mean time to local recurrence of 3.6 years and a mean time to distant recurrence of 5.7 years reported for whole-body synovial sarcoma.17 This highlights the importance of long-term follow-up for these usually younger patients. All patients should initially undergo monthly review, with thorough clinical examination including nasoendoscopy of the pharynx. Where resources permit, patients should also be offered follow-up PET scanning, as this is a sensitive test for detecting recurrent disease. This case represents a rare example of a monophasic synovial sarcoma of the pharynx. Diagnosis and treatment of this disease is difficult, and recurrence is common and occurs late. Prospective studies are required to further elucidate the roles of adjuvant and neoadjuvant radiation treatment and chemotherapy. 1 Endoscopic view of the oropharynx and piriform region There is severe narrowing of the airway at the level of the epiglottis. 2 Sagittal computed tomography image The synovial sarcoma almost completely occludes the laryngeal inlet.

Vikram Balakrishnan MB BS, BMedSc, DipSurgAnatomy · Sam Flatman MB BS, BSc · Benjamin J Dixon MB BS, FRACS · Bernard Lyons MB BS, FRACS

Selective oestrogen receptor modulators effectively reduce breast cancer in women at moderate to high risk, so why aren’t they being discussed routinely? Using medication to prevent breast cancer in women at moderate and high risk is a cost-effective1 and immediately implementable strategy for reducing the burden of breast cancer in Australia. There is Level 1 (strong) evidence that selective oestrogen receptor modulators (SERMs) such as tamoxifen and raloxifene reduce breast cancer risk by up to 40% in these women.2 The absolute risk reduction depends on an individual’s risk factor profile. These agents are rarely prescribed in Australia for breast cancer prevention (for complex but potentially modifiable reasons3) even in women at high risk, although they are now endorsed in an Australian guide and in the American Society of Clinical Oncology practice guideline.2,4 We summarise the evidence and suggest ways to implement this intervention in Australia. Women at high risk of breast cancer have the most favourable risk–benefit ratio, and hence are the focus of this article, but consideration of use of SERMs for women at moderately increased risk is also appropriate. Who is at high risk?The average lifetime risk of breast cancer for an Australian woman is 1 in 9 or 11%. A very small proportion (< 1%) of Australian women have a mutation in a major breast cancer predisposition gene, such as BRCA1, BRCA2, p53 or PTEN, resulting in a high lifetime risk for breast cancer of up to 80%. A larger group has a strong family history of breast cancer but no documented gene mutation. These women have a lifetime risk of at least 30%. A history of some types of benign breast disease and higher mammographic density also increase a woman’s risk. Importantly, an individual’s risk changes with age.5 To aid clinicians, the National Breast and Ovarian Cancer Centre (NBOCC) has developed a risk assessment guide and the online Familial Risk Assessment — Breast and Ovarian Cancer (FRA-BOC) risk assessment tool (one of several available6), (http://canceraustralia.nbocc. org.au/fraboc/). “High risk” throughout this article includes category 3 of the NBOCC guide (Box 1). Efficacy of SERMs for prevention of invasive breast cancerSeveral large randomised controlled trials (RCTs), which included over 25 000 women with at least moderately increased risk, have demonstrated the efficacy of SERMs.7-10 These trials showed that 5 years of tamoxifen use at 20 mg daily reduces breast cancer risk by 40%.2 The absolute benefit is thus between 12% and 32% for a woman at high risk (as defined in the previous paragraph), depending on her underlying absolute risk of breast cancer. Raloxifene is about 75% as effective as tamoxifen in postmenopausal women,11 with an arguably better side effect profile. Raloxifene has not been tested in premenopausal women. Both medications reduce the incidence of hormone receptor-positive cancers. SERMs also reduce breast density, which may facilitate earlier mammographic diagnosis of hormone receptor negative cancers.12 The reduction in breast cancer incidence is maintained for at least 5 years after a patient discontinues tamoxifen.2,7 Although none of the RCTs was powered for a mortality end point, reduced breast cancer incidence translates to reduced physical and psychosocial morbidity and treatment cost savings,1 and is a worthwhile and clinically meaningful end point. Possible side effectsThe commonest side effects of SERMs are hot flushes, sweats and altered vaginal secretions. In the RCTs, 10%–12% more women using tamoxifen had vasomotor and vaginal symptoms than in the placebo group; however, no difference was found in the incidence of depression, weight gain or overall quality of life.13 For the minority of women who experience significant problems, the SERM can be discontinued. SERMs double the risk for deep vein thrombosis and thromboembolism during use. The absolute incidence is around 4 per 1000 women-years of use (0.4% per year).11 For premenopausal women, with their low background risk of deep vein thrombosis, the absolute risk is even smaller; around 0.1% per year10 (comparable to the excess risk of thrombotic events in women who take third-generation oral contraceptives).14 SERMs did not significantly increase the risk for coronary heart disease or stroke in prevention trials.15 Women who smoke or those with a previous history of thrombosis should probably not be offered SERMs for risk reduction. Other contra-indications are listed in Box 2. Tamoxifen is associated with an excess risk of endometrial carcinoma of 0.25%–0.4% per year during use in postmenopausal women. The risk is not significantly increased in premenopausal women.10 Raloxifene does not increase the risk of endometrial cancer.11 Tamoxifen is a potential teratogen, and therefore is not appropriate for women planning pregnancy in the treatment period or women not using reliable contraception. There is a modest increase in the risk of cataracts (relative risk, 1.14; 95% CI, 1.01–1.29) in women taking tamoxifen.10 Bone density and fracture rates are improved by 5 years of SERM use after menopause,15 and raloxifene is currently prescribed for this indication. Current uptake of preventive SERMsBefore September 2010, the Australian NBOCC guide suggested consideration of prevention trials but made no recommendations about off-trial SERM use. Current use of SERMs preventively in Australia is very low. Of 3788 women at high risk of breast cancer enrolled in a national cohort study (kConFab), fewer than 3% have used SERMs for prevention, and only 0.3% have done so while not enrolled in a clinical trial.16 Alternatives to SERMsThe main alternatives to SERMs are screening and, for women at high risk, risk-reducing surgery (Box 3). Only 5% of women at high risk in the kConFab cohort have undergone risk-reducing surgery, and the vast majority are not using any preventive strategy.16,17 Annual breast imaging for early detection is suggested but does not reduce risk and is not proven to decrease mortality in premenopausal women at high risk.18 Aromatase inhibitors are under investigation for breast cancer prevention, with early results showing a benefit for exemestane,19 but longer term follow-up is needed, and use outside a clinical trial is not recommended in any guide. The International Breast Cancer Intervention Study (IBIS II), an RCT of anastrozole versus placebo, is currently recruiting participants in Australia. Barriers to uptakeThere are multiple potentially reversible barriers to recommendation of SERMs by clinicians and acceptance by women (Box 4). Some of these have recently been addressed, notably by revision of the NBOCC guide, which now suggests consideration of SERMs for women with moderate or high risk of breast cancer (Box 3). Referring to preventive SERMS as “chemoprevention” creates confusion with chemotherapy and results in negative attitudes towards this strategy.20 The consumer group Breast Cancer Network Australia recommends use of the term “risk-reducing medication” (Gerda Evans, Advocate, Breast Cancer Network Australia, personal communication, 24 August 2011). Tamoxifen is often imprecisely referred to as “hormone therapy”, potentially reducing its acceptance in a community aware of the risks of cancer with long-term hormone replacement therapy.21 Concern about side effects is common. Descriptions of relative rather than absolute risks of side effects can result in overestimation of the risk of rare side effects. This limits patient acceptance, as does lack of precision in estimating the magnitude of absolute benefit, which depends on multiple individual factors. Several contributors to the reluctance of doctors to prescribe SERMs are documented, and include a previous lack of endorsement of SERMs for risk reduction in guidelines, deficiencies in knowledge of risk assessment or patient selection, and time constraints.3 The new NBOCC guide and FRA-BOC risk assessment tool do much to address these issues. Australian doctors identify the lack of a Pharmaceutical Benefits Scheme subsidy as a barrier to prescribing, but tamoxifen and raloxifene are relatively inexpensive (less than $1 and $2.50 per day respectively) and likely to be within the means of most patients. Raloxifene is registered with the Therapeutic Goods Administration for the indication of breast cancer prevention in women at high risk, but registration for this indication has never been sought for tamoxifen and, as an off-patent drug, there is little incentive for pharmaceutical companies to champion its listing. This lack of registration for breast cancer prevention is cited as another barrier to prescription of tamoxifen. Nevertheless, off-label prescribing of tamoxifen is an appropriate approach because high-quality evidence exists to support its use.22 Tamoxifen and raloxifene are approved by the Food and Drug Administration for primary prevention of breast cancer in the United States. Who should prescribe?A minority of Australian women at increased risk of breast cancer regularly attend a risk management clinic where SERMs can be prescribed and monitored,23 but most require an alternative model of care. General practitioners and breast surgeons are ideally placed to identify women at increased risk and discuss, prescribe and monitor risk-reducing medication. GPs have a central role in prescribing for prevention of other conditions such as cardiovascular disease, and are a trusted source of prevention advice and management. Information is lacking on why Australian GPs and breast surgeons are not currently prescribing SERMs for prevention, but it is likely that they would benefit from further education and better tools to identify women at high risk. Tools such as the FRA-BOC risk assessor and the IBIS risk calculator (http://www.ems-trials.org/riskevaluator/) allow rapid assessment of breast cancer risk, but it remains difficult to quantitatively assess an individual woman’s absolute risk of side effects due to SERMs. Cancer Australia has developed a fact sheet which provides helpful information about contraindications and practicalities of prescribing. An evidence-based, online decision aid that enables personalised risk–benefit assessment is urgently needed. ConclusionAustralian women at moderate and high risk for breast cancer are not routinely offered SERMs, a proven preventive strategy. We hope that the recent update of the NBOCC guide including a suggestion for consideration of SERM use, along with the easy availability of online risk assessment tools, will increase preventive SERM use. Improved education and decision support for clinicians may help reduce the controversy surrounding the use of SERMs for breast cancer prevention and ultimately reduce breast cancer incidence. 1 National Breast and Ovarian Cancer Centre* breast cancer risk, by family cancer history criteria Category 2 (moderate risk for breast cancer) criteria Category 3 (potentially high risk for breast cancer) criteria One first-degree relative diagnosed with breast cancer before age 50 years; without the additional features of the high-risk group or Two first-degree relatives on the same side of the family diagnosed with breast cancer; without the additional features of the high-risk group or Two second-degree relatives on the same side of the family diagnosed with breast cancer, at least one before age 50 years; without the additional features of the high-risk group Two first- or second-degree relatives from the same side of the family diagnosed with breast or ovarian cancer plus one or more of the following (the same side of the family): additional relative(s) with breast or ovarian cancer breast cancer diagnosed before age 40 years bilateral breast cancer breast and ovarian cancer in the same woman Ashkenazi Jewish ancestry breast cancer in a male relative or Breast cancer in a first- or second-degree relative aged 45 years or less, plus sarcoma in another first- or second-degree relative aged 45 years or less, from the same side of the family or Member of a family in which a high-risk breast cancer gene mutation has been established, unless tested and found not to carry the family mutation or For women who are potentially at high risk of ovarian cancer, refer to http://www.nbocc.org.au/view-document-details/bog-advice-about-familial-aspects-of-breast-cancer-and-epithelial-ovarian-cancer * In July 2011, the National Breast and Ovarian Cancer Centre amalgamated with Cancer Australia to form a single national agency, Cancer Australia. 2 Contraindications to use of selective oestrogen receptor modulators in breast cancer risk reduction Pregnancy or absence of reliable non-hormonal contraception in a woman of childbearing potential History of endometrial hyperplasia Previous venous thromboembolic disease or inherited thrombophilia Patient is currently smoking Concomitant use of exogenous hormones (hormone replacement therapy or oral contraceptive pill) Premenopausal women should not be prescribed raloxifene 3 National Breast and Ovarian Cancer Centre management recommendations for women at moderate and high risk of breast cancer Preventive approach Moderate risk High risk Screening Annual mammogram from age 40 years if a first-degree relative younger than 50 years diagnosed with breast cancer Annual mammogram not recommended for women with one relative diagnosed with breast cancer after 50 years Regular clinical breast examination Annual breast imaging with mammography, magnetic resonance imaging or ultrasound Medical prevention For women over 35 years, consider tamoxifen or raloxifene to reduce risk Requires careful assessment of risks and benefits by an experienced medical professional Consider tamoxifen or raloxifene to reduce risk Risk-reduction surgery Discuss risk-reduction surgery Further assessment Consider referral to a family cancer clinic Advise referral to a family cancer clinic for risk assessment, possible genetic testing and management plan General recommendations Discuss modifiable risk factors* Encourage women’s awareness of normal look and feel of their breasts and reporting of changes Investigate symptoms using the triple test Discuss possible participation in a clinical trial for risk reduction or prevention† Discuss modifiable risk factors* Encourage women’s awareness of normal look and feel of their breasts and reporting of changes Investigate symptoms using the triple test Discuss possible participation in a clinical trial for risk reduction or prevention† * http://canceraustralia.nbocc.org.au/view-document-details/rfrw-breast-cancer-risk-factors-a-review-of-the-evidence. † For current clinical trials see http://www.australiancancertrials.gov.au, http://www.anzctr.org.au and http://www.anzbctg.org.au. 4 Barriers to uptake of medication to prevent breast cancer Barriers for prescribers Lack of Pharmaceutical Benefits Scheme subsidy Reluctance to prescribe off-label Many potential prescribers (eg, geneticists) do not follow up patients long term Potential prescribers feel inadequately resourced Perceived lack of endorsement (recently addressed in updated National Breast and Ovarian Cancer Centre guide) Barriers for women at risk Negative attitudes generated by use of words “chemoprevention” or “hormone therapy” Confusion between relative and absolute risks of side effects Fear of vasomotor side effects Inaccurate self-estimates of breast cancer risk Cost concerns

Sandra L Harvey BAppSc, MB BS, FRACP · Jane E Francis MA, MPH · Amanda J McBride MB BS · James F Bishop MD, MMed, MB BS · Kelly-Anne Phillips MB BS(Hons), MD, FRACP

To the Editor: The article by Baade and colleagues1 is valuable, but further research on clinical interventions and outcomes, as well as collaboration with other stakeholders, is required to improve care. The main result of Baade et al’s analysis of Queensland-wide population-based data was that overall survival of patients with rectal cancer decreases as distance from radiotherapy services increases. The article is important because it documents variation in overall survival of patients with rectal cancer according to where they live. Documenting outcome variation is a necessary first step along the path to improving service delivery. As Baade et al discuss, the next step is to identify the cause(s) of the variation. This next step could usefully investigate the quality of surgery. Non-randomised studies have shown that high-quality surgery with total mesorectal excision (TME) improves overall survival in patients with rectal cancer.2 In contrast, neoadjuvant or adjuvant radiotherapy has not yet been shown to improve overall survival, although, as Baade et al note, randomised controlled trials (RCTs) have shown reduced rates of local recurrence, with a corresponding improvement in disease-free survival.1 However, some experts have questioned the extent to which decreases in local recurrence rates, as measured in RCTs, lead to improvements in overall survival (given high-quality TME).3,4 Also, radiotherapy is not without risk (eg, sexual dysfunction, incontinence, bowel obstruction). Whether an individual patient (in consultation with his or her doctor) decides to have radiotherapy will depend on how he or she judges the trade-off between benefits and harms.4 In other words, identifying the cause(s) of variation in overall survival for patients with rectal cancer will not be easy because of the subtleties of everyday clinical practice. Moreover, the subsequent and final step in the pathway — implementing interventions to reduce unwarranted variation — is also not easy. We could make faster progress if there were closer collaboration among researchers in universities or institutes (who can generate new knowledge), budget holders in government (who can do something about modifiable causes of variation), and clinicians (who will be at the leading edge of any changes). A large amount of predictable health-services research is needed, and collaboration among researchers, budget holders and clinicians is as important as developing investigator-initiated ideas for research projects. Faster optimisation of service delivery could be achieved if budget holders were less suspicious of the motives of research groups,5 and if research groups put more emphasis on asking budget holders, “How can we help?”

Michael D Coory

To the Editor: We find ourselves in the curious position of criticising an article that supports improving access to radiotherapy. Baade and colleagues looked at cause-specific survival in all patients aged 20–79 years diagnosed with rectal cancer in Queensland.1 They found a 6% increase in cause-specific mortality risk for each 100 km increment in distance from the nearest radiotherapy facility. They concluded that the apparent poorer outcomes were due to a failure to receive radiotherapy. However, we suggest that their approach was significantly flawed in a number of ways. We have difficulty in understanding why, when information about the use of radiotherapy is available, this key explanatory factor was not actually measured. The size of the benefit they attribute to greater use of radiotherapy exceeds the expected improvements attributable to adjuvant radiotherapy compared with none at all.2 The authors state that pathological staging, another factor central to their analysis, is a reliable surrogate for clinical staging. However, they appear not to have made any allowance for the fact that neoadjuvant treatment leads to pathological down-staging. Finally, the main outcome, cause-specific survival, was taken from death certificates and is likely to be inaccurate. Use of radiotherapy is suboptimal in Australia.3 If the authors could identify the impact of distance on access to radiotherapy, this would be very valuable for cancer service planning. Clinical input is desirable in future investigations in this area.

Sean A Bydder · Nigel A Spry

In reply: We thank Bydder and Spry for their comments, although we suggest that they have misunderstood our study and its conclusions. We appreciate the opportunity to clarify our results. Our study provides clear evidence that, after rectal cancer diagnosis, differences in survival are directly correlated with how far patients live from radiotherapy facilities.1 We did not conclude, as stated by Bydder and Spry, that “the apparent poorer outcomes were due to a failure to receive radiotherapy”. This explanation would be simplistic and ignores the many, varied and complex factors (demographic, socioeconomic, geographical and clinical) that together contribute to poorer survival in regional and rural communities. Cause-of-death codes were based on case reviews by specialised coders using clinical information, in addition to the death certificate. Information on clinical stage is not available in population-based cancer registries and, for some cancers (including colorectal cancer), staging based on pathology reports has been shown to be a reliable substitute.2 Population-based data on radiation treatment are not available in Queensland. Finally, whether or not distance from radiotherapy facilities has a direct impact on access to radiation treatment, while outside the scope of our study, is an important question and, with our clinical collaborators, is indeed one focus of the next phase of our work.

Peter D Baade · Paramita Dasgupta · Joanne F Aitken · Gavin Turrell

Fast facts: chronic and cancer pain. 2nd ed. Michael J Cousins, Rollin M Gallagher. Oxford: Health Press, 2011 (167 pp, $25.00). ISBN 97819059832859. Australian Michael Cousins and American Rollin Gallagher are both internationally recognised pain medicine physicians, active in research, teaching and clinical work. Which is why, when my review copy of their book arrived in the post, I was surprised to find it to be so small. It made me recall Mark Twain’s famous comment: “I wrote you a long letter because I did not have the time to write a short one”, and hoped that the necessary time and thought had gone into this little handbook. I was not disappointed. The book explains the new insights into the physiology of persistent pain in a simple fashion. It is well illustrated and provides an up-to-date guide to various treatments. The chapters cover trigeminal neuralgia, complex regional pain syndrome, diabetic and post-herpetic neuropathic pain, central pain, musculoskeletal pain, visceral pain and headache. It is ideally suited to all medical practitioners treating pain including hospital medical officers, general practitioners and various medical specialists. It would also be useful to nurses, allied health clinicians, teachers and medical trainees. The book is balanced in its viewpoint, emphasising the multifactorial nature of persistent pain conditions, and that treatments require both medical as well as restorative approaches to physical function and psychological aspects. The chapter on cancer pain is well done. It offers a good overall summary of pathophysiology of cancer pain and the complications of therapy associated with pain. It summarises pharmacological, non-pharmacological and interventional strategies to manage cancer pain very succinctly. However, it comprises only a small section of the book and fails to cover palliative care or the existential nature of cancer pain and suffering. The introduction reminds readers that “regardless of specialty, clinicians will see patients with persistent pain”. I agree with this statement and, in my opinion, there is a need for concise texts about pain. The authors have definitely tapped into this need with this book.

Carolyn A Arnold

From Kurmond kid to cancer crusader. Pioneering integrated cancer treatment . Fred Stephens. Adelaide: Wakefield Press, 2011 (xiii + 177 pp, $29.95). ISBN 9781862549579. The fascination of an autobiography persists. Can the reader gain insight into the riddle of life by peering into the experience of another? Troubles, tribulations, successes and joys are scattered seemingly randomly across the human journey. So it is with Fred Stephens’ tale, a gentle, interesting story, almost naively presented in first person, extending from early childhood to an international career as a cancer surgeon. Stephens’ life spans a period of extraordinary change in Australian life, and those of the appropriate age will find much to engage with. The younger generation, however, are unlikely to believe that such primitive mid 20th-century life ever existed. The themes which pervade this recital have ongoing relevance to Australian life. Parochialism and nepotism have been a curse on this “lucky” country. The small number of tightly held and isolated medical communities, not excluding Sydney and Melbourne, encouraged dynasties and empire-building. Stephens’ tale accurately documents the impact of these elements on personalities and individual careers. Patients came first with Stephens, but patient-centred health care existed only as a dream. The final acceptance of the concept of surgical oncology by the Royal Australasian College of Surgeons is one of the bright spots. This book tells of a dedicated surgeon of independent mind doing well for his patients and the discipline of surgical oncology, but perhaps never receiving the recognition his achievements deserved. For those of us in the business and still fighting the good fight this is an enjoyable read, and well known characters pop up regularly through the pages. Fred Stephens was a pioneering spirit and his good heartedness and sometimes confronting personal honesty shines through the book.

Robert J S Thomas

Objective: To evaluate mammography screening outcomes in women with a personal history of breast cancer (PHBC), who have an increased risk of recurrent or new breast cancer, relative to women without PHBC.Design, setting and participants: Retrospective study of 713 191 screening mammograms from two groups of women — those with versus those without PHBC — who participated in the BreastScreen WA program in Western Australia between 1997 and 2006.Main outcome measures: Cancer detection rate (CDR), recall to assessment rate, recall positive predictive value (PPV) for cancer, and distribution of cancer characteristics within and between the two groups.Results: Screening detected 4125 breast cancers: CDR per 10 000 screens was significantly higher in women with PHBC (95.5; 95% CI, 78.3–112.7) than in women without PHBC (57.2; 95% CI, 55.4–58.9). Recall to assessment rate per 10 000 screens was lower in women with PHBC (385.2; 95% CI, 350.6–419.8) than in women without PHBC (504.9; 95% CI, 499.7–510.2). Recall PPV was higher for women with PHBC (24.8%; 95% CI, 21.0%–28.9%) than those without PHBC (11.2%; 95% CI, 10.9%–11.6%). Cancer characteristics were consistent with early detection (most were smaller than 2 cm and node-negative) and were similarly distributed in both groups, except for tumour grade, with PHBC women having fewer low-grade cancers and slightly more high-grade cancers than women without PHBC.Conclusions: The relative rate of cancer detection between women with PHBC and women without PHBC who attended an Australian population-based breast screening program was similar to estimates from international studies. Recall rates were within national standards. Screen-detected cancers had similar characteristics in both groups, except for tumour grade. These data support national integration of mammography screening for women with PHBC into BreastScreen, although evaluation of interval cancers will be necessary.

Nehmat Houssami MB BS, FAFPHM, PhD · Janette J Tresham BSc(Agric) · Lin Fritschi MB BS, FAFPHM, PhD · Liz E Wylie MB BS, FRANZCR

Fast facts: brain tumours. 2nd ed. Lauren E Abrey, Warren P Mason. Oxford: Health Press, 2011 (143 pp, $19.50). ISBN 9781905832873. Brain tumours are the cause of the greatest loss of life-years per person from any cancer, but account for only 2% of all cancers. The first Australian Guidelines were published only in 2009. There is overwhelming consensus that brain tumours should be managed by a dedicated multidisciplinary team of neurosurgeons, medical and radiation oncologists, and nursing, social work rehabilitation and palliative care specialists. It is not clear who needs Fast facts. The authors, a neurologist and medical oncologist from major oncology centres in North America, have written it in a style that is only suitable for clinicians. Specialists will not find much that is new. Allied health practitioners new to neuro-oncology and medical students may be interested in a concise précis of current practice for the modest price of $20 but may prefer the Australian Guidelines, which are more detailed and are available for free from the Cancer Council Australia website. A version of the guidelines has been written for patients and carers. Fast facts discusses epidemiology, diagnosis and treatment and includes chapters on the more common types of brain tumours; however, rehabilitation, palliative care and supportive care are not covered. Brain tumour patients are rarely fit to drive, yet this important restriction is not mentioned. Older people are frequently undertreated because of concerns about their prognosis. The authors recommend treatment strategies based on the fitness of the patient rather than their age. The standard of illustration is good with many images of a wide range of clinical conditions. Brachytherapy, a disproved technique, is illustrated but radiosurgery is not. References are lacking but further reading is given at the end of each chapter, although some of the readings are over a decade old. The management of brain tumours should not be in the hands of those who need to fill gaps in knowledge “fast”. It is a complex and difficult area best managed by expert multidisciplinary teams.

Michael B Barton

Objective: To determine whether an association exists between distance from radiotherapy facilities and survival outcomes of people diagnosed with rectal cancer.Design and setting: Descriptive population-based study using data from the Queensland Cancer Registry.Patients: All patients aged 20–79 years (n = 6848) diagnosed with invasive rectal cancer between 1 January 1996 and 31 December 2006.Main outcome measure: Cause-specific survival.Results: The 5-year cause-specific survival was 62% (95% CI, 61%–64%); it was strongly influenced by stage at diagnosis (American Joint Committee on Cancer, Stages I–IV), ranging from 86% (Stage I) to 9% (Stage IV). After adjusting for age, sex, and stage at diagnosis, patients who lived 100–199 km, 200–399 km and 400 km or more from a radiotherapy facility were 16%, 30%, and 25%, respectively, more likely to die from rectal cancer than patients living within 50 km of such a facility. On average, there was a 6% increase in mortality risk (95% CI, 3%–8%; P < 0.001) for each 100 km increment in distance from the nearest radiotherapy facility. Shared frailty models showed that this association persisted after adjusting for the correlation between individual cancer patients living in the same remoteness or area-level socioeconomic status categories.Conclusions: While centralisation of cancer treatment services has merit, our study provides evidence of a shorter survival for people with rectal cancer who live relatively far from radiotherapy facilities. It remains a priority to develop and implement policy, cultural and clinical measures to reduce the burden faced by rural and remote patients with rectal cancer.

Peter D Baade PhD, MMedSc, BAppSc(Hons) · Paramita Dasgupta PhD, MSc, BSc(Hons) · Joanne F Aitken PhD, MSc, BSc(Hons) · Gavin Turrell PhD, BA(Mgt/Adm)

Objective: To determine trends in incidence of malignant mesothelioma (MM) caused by exposure to asbestos during home maintenance and renovation.Design, setting and participants: Using the Western Australian Mesothelioma Register, we reviewed all cases of MM diagnosed in WA from 1960 to the end of 2008, and determined the primary source of exposure to asbestos. Categories of exposure were collapsed into seven groups: asbestos miners and millers from Wittenoom; all other asbestos workers; residents from Wittenoom; home maintenance/renovators; other people exposed but not through their occupation; and people with unknown asbestos exposure; or no known asbestos exposure. Latency periods and age at diagnosis for each group were calculated and compared.Results: In WA, 1631 people (1408 men, 223 women) were diagnosed with MM between 1960 and 2008. Since 1981, there have been 87 cases (55 in men) of MM attributed to asbestos exposure during home maintenance and renovation, and an increasing trend in such cases, in both men and women. In the last 4 years of the study (2005–2008), home renovators accounted for 8.4% of all men and 35.7% of all women diagnosed with MM. After controlling for sex and both year and age at diagnosis, the latency period for people exposed to asbestos during home renovation was significantly shorter than that for all other exposure groups, but the shorter follow-up and difficulty recalling when exposure first occurred in this group may partly explain this.Conclusions: MM after exposure to asbestos during home renovation is an increasing problem in WA, and these cases seem to have a shorter latency period than other types of exposure. MM cases related to renovation will probably continue to increase because of the many homes that have contained, and still contain, asbestos building products.

Nola J Olsen BAppSc, RGN · Peter J Franklin BSc(Hons), PostGradDipEnvSci, PhD · Alison Reid RGN, MSc, PhD · Nicholas H de Klerk BSc, MSc, PhD · Timothy J Threlfall MB BS, MPH, PhD · Keith Shilkin FRCPA, FCRPath, FHKCPath · Bill Musk FRACP, MSc, MD

CorrectionsIncorrect percentage: In “Prevalence and predictors of anxiety and depression in women with invasive ovarian cancer and their carergivers” in the Anxiety, depression and cancer supplement to the 6 September 2010 issue of the Journal (Med J Aust 2010; 193: S52-S57), the percentage given in Box 2 (page S54) for participants categorised as having a normal score for anxiety on the Hospital Anxiety and Depression Scale was 60.8%. The correct percentage is 66.8%. This error has no impact on any of the analyses, results or conclusions of the article; it has been corrected in the online version (http://www.mja.com.au/public/issues/193_05_060910/pri11382_fm.html).

Melanie A Price · Phyllis N Butow · Daniel S J Costa · Madeleine T King · Lynley J Aldridge · Joanna E Fardell · Anna DeFazio · Penelope M Webb

To the Editor: The Australian state of Queensland has one of the highest rates of melanoma and non-melanoma skin cancer in the world.1,2 Solar ultraviolet (UV) radiation is the most important environmental risk factor,3 highlighting the need for sun safety education and skin cancer screening among outdoor workers in Queensland. Many such programs are currently in place, including the Sunsafe Workplace Program developed by the University of Queensland in collaboration with the Queensland Skin and Cancer Foundation in 2007. In August 2010, we attended an outdoor workplace in Brisbane, with extensive sun safety policies already in place, to perform free voluntary skin checks on employees. Of 55 people invited to participate, 39 accepted. Of these, 36 were male, the median age was 35 years (range, 19–62 years), and 28 were of British and/or Irish ancestry. Eighteen participants reported spending 5–8 hours a day outdoors mid week and 20 reported the same at weekends. Six reported that at the start of summer, they never tanned and always burned, and 31 reported burning first, then tanning. Nearly half reported having had more than five painful sunburns in their lifetime. Despite these results, only a third of participants (13) reported wearing sunscreen, less than half (17) reported wearing a hat, and two-thirds (26) reported wearing sunglasses more than 50% of the time. Of the 39 participants, we referred one to his general practitioner for management of two non-melanoma skin cancers. About half of the participants reported having had formal skin checks before. Of these, one had previously had melanoma and five had non-melanoma skin cancers, and 10 had one or more suspicious naevi removed in their lifetimes. The main reasons given for not having had a previous skin examination were fear of skin cancer diagnosis and difficulty attending appointments during working hours. We found that providing easy access to free on-site skin examinations reduced interference to the work day, made appointments more accessible (both physically and financially), and enabled us to provide personalised information about participants’ skin and skin cancer risks and reassure those who had been anxious about receiving skin cancer diagnoses. We found that workers were relieved when told they had nothing suspicious presenting on the day, and that they seemed less anxious about seeking skin checks in the future. Despite many public awareness campaigns on skin cancer and the establishment of sun safety programs in the workplace, we found there is still room for improvement. Although clinical guidelines do not currently recommend routine skin cancer screening for the general population,4 the success of our visit leads us to encourage workplaces that are exposed to solar UV radiation to consider providing on-site skin examinations for employees, as well as ongoing sun safety education. We believe such services can help to break down barriers that prevent people from seeking medical assessment and management, and can help to spread the safety-in-the-sun message.

Nicola C Douglas · Laura Baillie · H Peter Soyer