Cancer

A 57-year-old man had a colonoscopy which revealed a partially obstructing polyp in the rectum. Biopsy revealed an adenocarcinoma. A computed tomography scan of the abdomen revealed multiple low-attenuation lesions diffusely throughout the liver (Box). Differential considerations included multiple small hepatic cysts, Caroli’s disease, microabscesses and metastases. The patient had a low anterior resection for his rectal tumour and wedge biopsy of the liver. Macroscopically, there were multiple 2–3 mm white nodular lesions throughout the liver, with the macroscopic appearance of diffuse liver metastases. Pathology of the liver biopsy revealed von Meyenberg complexes. Von Meyenberg complexes are benign liver malformations that play an important part in the differential diagnosis of liver lesions. The clinical significance is that they are easily misdiagnosed as multiple liver metastases on imaging, or even on gross examination.1 Because the presence of liver metastasis is crucial to the correct therapeutic approach, ruling out other possible diagnoses, such as von Meyenberg complexes, is of great importance. Von Meyenberg complexes in the liver A: Non-contrast computed tomography (CT) scan of the abdomen showing multiple diffuse, low-attenuation lesions throughout the liver. B: CT scan of the abdomen with contrast showing multiple low-attenuation, non-enhancing lesions throughout the liver.

Bassem M Chehab MD · Shaker R Dakhil MD, FACP

Objective: To measure and compare the casemix and diagnostic accuracy of excised or biopsied skin lesions managed by mainstream general practitioners and doctors within primary care skin cancer clinics.Design, setting and participants: Prospective comparative study of 104 GPs and 50 skin cancer clinic doctors in south-eastern Queensland, involving 28 755 patient encounters. The study was conducted in 2005.Main outcome measures: Prevalence of each type of skin lesion; sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the clinical diagnosis against histology; number needed to excise or biopsy (NNE) for a diagnosis of skin cancer.Results: GPs excised or biopsied 3175 skin lesions (mean 2.5/week) including 743 basal cell carcinomas (BCCs) (23.4%), 704 squamous cell carcinomas (SCCs) (22.2%) and 49 melanomas (1.5%). Skin cancer clinic doctors excised or biopsied 7941 skin lesions (mean 34/week), including 2701 BCCs (34.0%), 1274 SCCs (16.0%) and 103 melanomas (1.3%). Overall, sensitivity for diagnosing any skin cancer was similar for skin cancer clinic doctors (0.94) and GPs (0.91), although higher for skin cancer clinic doctors for BCC (0.89 v 0.79; P < 0.01) and melanoma (0.60 v 0.29; P < 0.01). The overall NNE was similar for skin cancer clinic doctors (1.9; 95% CI, 1.8%–2.1%) and GPs (2.1; 95% CI, 1.9%–2.3%). This did not change after adjusting for years of clinical experience.Conclusions: GPs and skin cancer clinic doctors in Queensland treat large numbers of skin cancers and diagnose these with overall high sensitivity. The two groups diagnosed skin cancer with similar accuracy.

Philippa H Youl MPH · Peter D Baade PhD · Monika Janda PhD · Christopher B Del Mar MD · David C Whiteman PhD · Joanne F Aitken PhD

To the Editor: The recent editorial by Macrae1 outlined the potential issues facing the rollout of the National Bowel Cancer Screening Program. It is estimated there will be about 5000 additional colonoscopies performed in New South Wales in the first year.2 To ascertain how the NSW public health system might absorb this increased demand, the Greater Metropolitan Clinical Taskforce (GMCT) Gastroenterology Network conducted a survey in 2006, featuring structured interviews with clinicians. Our aims were to estimate the current capacity of NSW public hospitals to perform colonoscopies and to identify perceived impediments to meeting future demand. From a total of 113 public hospitals where colonoscopies had been performed in the period 2001–2004,3 we selected a purposive sample of 32 where there had been at least 500 procedures, or which were regarded as major providers in their area health service. Responses were received from 26 hospitals, which represented 54% of colonoscopies performed in all public hospitals in NSW in 2001–20043 and included both metropolitan and rural hospitals. No information was collected from the private sector. Fifteen hospitals had dedicated endoscopy suites, 10 used operating theatres, and one unit used a day surgery centre. We found that for the majority of these hospitals (23/26), colonoscopy activity is currently at or near maximal capacity, with limited potential for expansion of services. The additional number of colonoscopies that could be accommodated ranged from one to four per week in six hospitals, up to a maximum of eight per week in a single hospital. Reasons for unbooked hours included insufficient funds, and a lack of nurses and anaesthetists. The Box summarises other key findings, which emphasise that the three major factors limiting activity are insufficient endoscopy nurses, insufficient nursing applicants, and the need for more equipment. Importantly, an absolute shortage of proceduralists was not found to be a restricting factor. Rather, insufficient available colonoscopy time for existing proceduralists was identified as a limitation. While our survey was successful in clarifying factors that impede optimal performance, the small number of participating hospitals is a relative limitation. Nevertheless, the survey suggests a requirement for additional nursing staff and equipment, and for the establishment of uniform data collection and reporting systems. Areas requiring further exploration include greater unit efficiency, opportunities for workplace redesign, and consideration of inequities in access to anaesthetic cover for patients in public hospitals. The GMCT Gastroenterology Network is currently working on these issues in collaboration with the NSW Department of Health. Factors affecting colonoscopy capacity in selected New South Wales public hospitals* Most responding units (22/26) regarded additional nursing staff as a medium to high priority requirement Increasing time available to existing proceduralists (18/25) and allocating time for new proceduralists (16/25) were regarded as medium to high priorities 11/15 hospitals with dedicated endoscopy suites had an unused endoscopy room. Most common reasons were: insufficient funds (5); lack of nurses (5); insufficient equipment, including anaesthetic machines (3); and lack of anaesthetists (2) No unit cited a shortage of proceduralists as a reason for the unit not running at full capacity “For” (11/24) and “against” (13/24) responses for the addition of procedure rooms were evenly spread across responding facilities Prioritisation of colonoscopies over other procedures was not favoured (14/24 ranked this of low importance, 5 as neither low nor high, 5 as medium to high) Most important factors impeding capacity were: Lack of approval to recruit nursing staff (18/23) Shortage of nursing staff applicants (16/25) Budgetary limitations (19/25) Insufficient endoscopy time for existing proceduralists (17/25) Insufficient budget to recruit new proceduralists (16/23) Only 2/26 units (both using operating theatres) had a data manager recording data and compiling statistics; others (13/26) in dedicated endoscopy suites used commercial reporting systems, such as Endoscribe, however the survey did not determine how systematically and completely data were compiled and reported from these systems * Some respondents did not answer all questions.

Shelanah A Fernando · Anne E Duggan · Owen F Dent · Maeve C Eikli

To the Editor: I note with interest the results of the study by Morris and colleagues comparing survival outcomes for patients with colorectal cancer treated in public and private hospitals.1 Stage of disease is a major determinant of survival in colorectal cancer, yet, as stated in their article, stage of disease was derived solely from pathology reports. I believe that this method would have very limited accuracy in diagnosing stage IV disease. Determining stage IV disease requires additional investigations such as computed tomography, which may either not have been performed before surgery, or the results of which may not have been noted on the pathology request form. Underdiagnosis of stage IV disease appears likely, as the incidence of stage IV disease of about 10% noted in this study is substantially less than the 20%–25% incidence observed in other epidemiological studies.2 Moreover, the limitations associated with the use of pathology reports to determine stage IV disease have been observed by other investigators.3 Although this study evaluates an interesting question in relation to the management of colorectal cancer, the significant possibility of an imbalance of important prognostic factors (such as tumour stage) between public and private patients creates major doubt about its conclusions.

Niall C Tebbutt

To the Editor: We suggest that marked differences in comorbidities could be one explanation for the superior outcomes for patients with colorectal cancer treated in private hospitals as reported in the study by Morris et al.1 We also have concerns about the quality of the data used in their study. We used a comprehensive prospective database to examine a cohort of Victorian patients treated at the Royal Melbourne Hospital (n = 260) and the adjacent Melbourne Private Hospital (n = 118) between 2003 and 2006. Specifically, we included data on important patient variables that were not considered in the Western Australian series (Box). These data showed a clear bias towards improved postoperative and long-term survival outcomes for patients in the private system, independent of cancer treatment. Significantly, diabetes, which affected a much larger proportion of public than private hospital patients, is also associated with inferior cancer-specific outcomes.2 Together, these results could explain the differences reported by Morris et al. In support of this, the 5-year cancer-specific survival rates they report for stage I cancer in the two hospital groups is similar (89% public versus 92% private), but the overall survival rates are markedly different (74% public versus 85% private) — consistent, we contend, with an excess of non-cancer deaths in public patients. Morris et al also report an imbalance in the receipt of adjuvant chemotherapy between public and private patients, possibly a marker of inequality of care. We analysed prospectively collected data for our patients with stage III colon cancer, where adjuvant chemotherapy has a proven impact on survival. As shown in the Box, a similar percentage were offered, accepted and completed adjuvant chemotherapy, suggesting, in Victoria at least, similar access to care and support for public and private patients. The pathology-based staging used by Morris et al may also be inaccurate, as recording of stage IV disease relies on the surgeon noting this on the pathology request form and patients having been fully evaluated before surgery (we contend that preoperative computed tomography scanning would not have been routine). This may explain the relatively low percentage of patients recorded as having stage IV disease (12% public; 9% private) compared with 17% in our combined series in which prospective clinicopathological staging was used. Finally, inaccurate data are suggested by the reported 5-year overall survival figures for patients with stage IV cancer (17% in private care).1 That this is superior to figures reported in recent clinical trials is an unexpected finding, particularly as clinical trials enrol only a select subset of patients and provide access to novel combination chemotherapy, and presentation with metastatic disease is an adverse prognostic factor. Comparison of public and private hospital patients with colorectal cancer Public hospital Private hospital P Number of patients 277 122 Smoker 141 (51%) 16 (13%) < 0.001 Diabetes 57 (21%) 8 (7%) 0.002 Emergency presentation 22 (8%) 2 (2%) 0.02 ASA score* 1 28 (10%) 36 (30%) 2 131 (47%) 32 (26%) 3 89 (32%) 22 (18%) 4 15 (5%) 0 Unknown 14 (5%) 32 (26%) Stage III colon cancer 64 38 Chemotherapy advised 50 (78%) 30 (79%) 0.22 Patient followed advice 44 (88%) 29 (97%) 0.12 Chemotherapy completed 28 (64%) 21 (72%) Chemotherapy not completed 16 (36%) 8 (28%) Toxicity 7 (44%) 3 (38%) Patient request 4 (25%) 0 Ongoing computed tomography 3 (19%) 4 (50%) Other 2 (12%) 1 (12%) * American Society of Anesthesiologists physical status score.

Suzanne Kosmider · Ian T Jones · Ian P Hayes · Peter Gibbs

In reply: The first issue is whether we accurately identified patients with stage IV disease, as the incidence in our study was only 11% and the anticipated incidence is normally 20%–25%. We agree that simply reviewing pathology reports would tend to underdiagnose stage IV disease. However, all patients were crosschecked to the linked database to see if they had had a computed tomography scan or ultrasound image showing metastatic disease. In addition, we only reviewed patients whose primary cancer was resected. This excluded about a third of all the patients with stage IV disease. In my (C P) own surgical prospective colorectal cancer database of 781 patients, (1996 to 2007), 24% of the 185 referred with colorectal cancer had stage IV disease (private hospital patients, 21% v public hospital patients, 25%). Resection of the primary cancer was only undertaken in 126 of the 185 patients with stage IV disease (68%). Therefore, only 16% of all patients with colorectal cancer who had resections had stage IV disease (126/781). Tebbutt argues that there could be a possibility of some imbalance between public and private patients based on this observation. We argue that the difficulty in diagnosing stage IV disease applies equally to public and private patients. Similarly, my own database does not show a significant difference in the incidence of stage IV disease between public and private hospital patients. Kosmider et al report that, at their own institution, completion rates for chemotherapy for stage III colon cancers are the same for public and private patients, “. . . suggesting, in Victoria at least, similar access to care and support for public and private patients”. These results are hardly comparable with our study. Their observations are limited to a select subgroup and only relevant to a small section of the Victorian population, where there is a collocated public and private hospital. In contrast, our study included the entire population of Western Australia, and all public and private hospital patients. Interestingly, we noted wide variations in the rates at which chemotherapy was used, not only between public and private hospitals, but also between individual hospitals. We also noted that there are few collocated public and private hospitals within WA. The fact remains that, at a population level, public hospital patients in WA were less likely to receive chemotherapy. Finally, Kosmider et al raise the issue that comorbidities can influence overall and cancer-specific survival (especially in relation to diabetes). We recognise this as a weakness of our study, and highlighted it in the discussion. Nonetheless, we did include a number of measures of social disadvantage in the analysis. Such measures can act as surrogate markers of common comorbidities. For example, there is a fairly clear association between type 2 diabetes and disadvantage.1 We therefore do not believe that comorbidities can account for all of the observations seen in our study. Our conclusion therefore remains — that patients with colon and rectal cancer treated in private hospitals in WA had superior outcomes. In reality, given the inequities between the two systems, is this really so surprising?

Cameron Platell · Melinda Morris · Barry Iacopetta

During 1994–2006, 10 cases of invasive breast cancer were diagnosed among 550 women employed for some time at a broadcast media site in Brisbane, Queensland. These cases represented a more than sixfold increase in risk compared with the female population of Queensland. After an initial unsatisfactory inquiry, an independent assessment was successful when the investigation addressed environmental factors of concern to the employees, as well as agents that may have accounted for the cluster. The perceptions of the women affected were documented in the television program Australian Story. No specific cause of the cluster was identified, but staff concerns were allayed by relocation from the site. The outcome suggests a specific duty of care involving adequate attention being paid to community needs in such situations.

Bernard W Stewart PhD, FRACI, DipLaw

Cancer is the leading cause of death among Australians, causing 28% of all deaths. The average general practitioner will only encounter about four new patients each year with a potentially fatal cancer. A GP’s cancer-related workload mostly involves prevention, and dealing with patients with suspicious symptoms or concerns about possible cancer, or who may be at increased risk due to family history or lifestyle factors. GPs cover the full spectrum of cancer care from prevention to palliation, including providing psychosocial support to patients and their families and carers. GPs have a key role in early diagnosis and referral, follow-up and detection of recurrence, and survivorship. There is a developing role for GPs in cancer policy and research.

Brian R McAvoy MD, FRCP, FRACGP

Despite advances in treatment, the greatest gains in cancer control are achieved through prevention The translation of basic cancer research on cell growth to the clinic has resulted in a paradigm shift in cancer treatment by providing new therapeutic targets. The initial successes — the monoclonal antibodies trastuzumab and rituximab — have improved the survival of patients with breast cancer and lymphoma, as has the small molecule imatinib mesylate in chronic myeloid leukaemia; all have less toxicity than conventional cytotoxics.1 The challenge is to fund these new high-cost drugs. Although targeted drugs can be limited to the specific patient populations expressing the appropriate target, further funding is then required to screen patients for those targets. New models of cost- and risk-sharing between governments and industry must evolve to pay for these developments. A similar evolution in the diagnosis of cancer will see genomics and proteomics become a more important guide to treatment selection and prognosis than traditional pathology tests.2,3 These research technologies will need to be developed in such a way that they can provide guidance to clinicians as quickly as conventional techniques, and will also require upskilling of current clinicians, pathologists and their trainees. Investment in cancer research pays considerable dividends.4 There is a need for more funding of translational research — it has been an ongoing concern that Australia lacks the infrastructure to take promising new drug discoveries all the way from the laboratory into clinical practice. Newer fields, such as health services research, with its potential to address the pressing issue of inequities in access to treatment and cancer outcomes in rural and remote Australia, and psychosocial research, require new sources of funding. The challenge in Australia is to make research less fragmented and better targeted to questions of international importance, which we have the capability to competitively pursue. Although breakthroughs in cancer treatment generate significant media coverage, the greatest gains in cancer control in Australia are to be made in prevention strategies based on established science. Evidence-based health promotion campaigns have provided strong economic returns, yet governments invest only 1.7% of the overall health care budget in primary prevention.5 More than 21% of cancer deaths in Australia are attributed to tobacco use. Add smoking to excessive sun exposure, inadequate fruit and vegetable intake, alcohol, inactivity and obesity, and more than 34% of cancer deaths in Australia can be attributed to modifiable behaviour.6 Currently, 17.4% of Australians smoke.7 Australia has a smoking prevalence among the world’s lowest, but from a public health perspective it remains unacceptable that almost one in five Australians incurs a significant yet avoidable cancer risk by continuing to smoke. The prohibition of broadcast tobacco advertising in the mid 1970s was the first key policy step in a series of tobacco control reforms that have since been shown to have saved 17 000 Australians from premature death.8 This government initiative required no taxpayer funding, but a cultural shift. Where funds have been invested, the returns have been enormous, with the $176 million spent on antismoking campaigns over the past 30 years delivering $8.6 billion in benefits.9 There remains no more effective cancer control measure than reducing smoking, but there is a risk that the incremental reduction in smoking prevalence achieved over the past 30 years will stall unless the tobacco control effort is sustained. Smoking also contributes significantly to social inequities in health outcomes. For example, a smoking prevalence of 50% among Indigenous Australians10 is believed to be a major cause of the significantly poorer cancer survival rates among Aboriginal and Torres Strait Islander peoples. Targeted approaches are needed to break the cycle of social disadvantage, smoking, and cancer evident in specific population groups. Moreover, studies on tobacco control achievements over recent decades strongly suggest that a more sustained, whole-of-government commitment, built around integrated policy, social marketing, and research, could bring smoking prevalence down in Australia by a further 1% annually. Estimates based on recent trends indicate that reducing smoking prevalence by 5% in 5 years would save more than $1.15 billion in health care costs over the next 30 years.8 Yet some major political parties continue to accept donations from tobacco companies,11 and governments delay legislation to ban smoking in enclosed public spaces, and invest taxpayer funds in tobacco companies on the basis of sound economic management — despite having to spend more taxpayer funds on treating tobacco-related diseases (at least until patients die of them). While public policy has been gradually reducing the tobacco burden, obesity is escalating as a community health crisis. Obesity is linked to colorectal cancer, postmenopausal breast cancer, and kidney, oesophageal, gall bladder and endometrial cancers.12 Obesity control includes encouraging and facilitating physical activity and communicating dietary advice. The tobacco experience suggests that restricting junk-food advertising to children is likely to have an important impact, as supported by early Canadian data.13 This measure is not about restricting choice, as well targeted multimillion-dollar advertising campaigns already create an imbalance in the choices that uninformed and often disadvantaged families see as being available to them. Other lifestyle messages require more subtle public education. Advice from the SunSmart skin cancer prevention program must balance the need to avoid excessive sun exposure with the importance of low-level sunlight for vitamin D production. Similarly, while any alcohol consumption carries some cancer risk, the more you drink, the higher the risk — a factor that should be balanced against the benefits of very low alcohol intake in preventing cardiovascular disease. Cancer screening is another area that is presenting new opportunities and challenges. The benefits of breast cancer screening need to be continually reinforced to ensure high participation rates by eligible women. A new challenge for cervical cancer screening is ensuring continued high participation despite the introduction of the human papillomavirus immunisation program. The new National Bowel Cancer Screening Program requires community and professional education, a patient registry to ensure follow-up, and extra resources and minimum standards to meet increased colonoscopy demand. This will test the shared responsibilities for health care between national and state/territory governments — a potential barrier to efficient health policy implementation. The community must also understand that an ineffective screening test — one that evidence shows lacks the specificity and sensitivity to reduce cancer mortality on a population basis — is worse than no test at all, as the false positives and negatives can lead to poorer health outcomes than would surveillance on a case-by-case basis. The key is ensuring that evidence guides the implementation of government-funded measures aimed at cancer prevention and early detection — at a time when we could prevent well over a third of all cancer deaths in Australia using existing prevention and early detection technology. By investing more taxpayer funds in the high proven returns of cancer prevention and early detection, we could make resources available to better support the significantly increasing numbers of new cancer patients associated with population ageing over the coming years. Savings generated through improved prevention could also fund targeted cancer research to help further reduce the impact of cancer in the future. Increasing the cancer workforce, and improving workforce training and support through a more integrated approach across jurisdictions, is also pivotal to ensuring we can provide optimal multidisciplinary cancer care to meet the challenges of the future.

Ian N Olver MD, PhD, FRACP

Objectives: To describe the self-reported use of prostate specific antigen (PSA) tests, faecal occult blood tests (FOBTs), and whole-body skin examinations among Queensland men, reasons for use, and the personal characteristics of men undergoing the tests for cancer screening.Setting and design: Data were obtained from the Queensland Cancer Risk Study (QCRS), a population-based telephone survey conducted in 2004, which used random sampling stratified by age, sex, and geographic location.Participants: All men aged 50–75 years who participated in the QCRS (n = 2336).Main outcome measures: Use of PSA test, FOBT, or whole-body skin examination, specifically as a screening procedure; the probability of being screened; and associations with sociodemographic factors, risk behaviour, and cancer experience.Results: More than a third of men reported never having been screened for prostate, colorectal, or skin cancer. Of those who had been screened, the odds of PSA testing being reported were more than two times greater than the odds of whole-body skin examination (adjusted odds ratio [OR], 2.54; 95% CI, 1.49–4.32), and the odds of reporting an FOBT were less (adjusted OR, 0.48; 95% CI, 0.22–1.04). Men who participated in cancer screening tended to be older, white, living with a partner, and to have private health insurance. Smokers were less likely to be screened with any of the three screening tests.Conclusions: Of these three cancer screening tests, the FOBT has the best evidence for reducing mortality and yet is the least frequently used by Queensland men. There are disparities in reported screening prevalence between the specific tests and across certain population subgroups.

Philippe Carrière MD, MSc · Peter Baade PhD, AStat · Beth Newman PhD · Joanne Aitken PhD · Monika Janda PhD

A 50-year-old woman presented to her dermatologist in 1999 with a 6-month history of recurrent pruritic scaly plaques on the abdomen, arms and hairline. The rash, which was presumed to be seborrhoeic dermatitis, improved after treatment with systemic prednisolone. No skin biopsies were taken at the time. In 2004, she developed a leonine facies (Box, A), widespread erythroderma, alopecia, generalised peripheral lymphadenopathy, hyperkeratosis of the palms, and bilateral swollen pinnae with otorrhoea (Box, B). Punch biopsies revealed Pautrier microabscesses containing atypical CD4+ lymphocytes. A peripheral blood film showed Sézary cells, confirming Sézary syndrome. The patient’s condition deteriorated despite treatment with methotrexate, prednisone, bexarotene, interferon, psoralen and ultraviolet A, as well as extracorporeal photopheresis. Radical palliative radiotherapy to the head and neck improved her leonine facies and otitis externa (Box, C). The patient died in 2006, 8 years after initial presentation. Sézary syndrome is a rare, aggressive, cutaneous T-cell lymphoma characterised by widespread erythroderma, atypical peripheral lymphocytes (Sézary cells) and lymphadenopathy. Cutaneous T-cell lymphomas typically present as indolent cutaneous eruptions and are often misdiagnosed at initial presentation, as the skin lesions mimic common dermatological disorders such as eczema or psoriasis. A: Leonine facies. B: Oedematous right pinna. C: Left pinna after radiotherapy.

David R Waterhouse MB ChB · Subhaschandra Shetty MB BS, MS(ENT) · Jeremy S Gathercole MRCS, LRCP, FRACS · Christopher J Seeley MB ChB, FRACS

Objective: To evaluate whether prolonged waiting times for colonoscopy in public hospitals could result in delayed diagnosis of colorectal carcinoma.Design, setting and patients: Analysis of all outpatient colonoscopies performed at a Western Australian tertiary teaching hospital, 1 November 2003 – 31 October 2005. Colonoscopy data, corresponding pathological findings, category of urgency at referral for colonoscopy, and waiting time for colonoscopy were obtained. Patients were coded as having cancer if it was diagnosed by colonoscopy or if colonoscopy identified a lesion subsequently diagnosed as cancer.Main outcome measures: Colorectal carcinoma detected by outpatient colonoscopy and length of waiting time to colonoscopy.Results: 1632 outpatient colonoscopies were recorded. Category I patients received a colonoscopy within the recommended 30 days from referral. Median waiting times for Category II and Category III patients exceeded recommendations (observed, 113 days and 258 days; recommended, within 90 days and 180 days, respectively), although the number of cancers detected was low (2.4% and 0.6% of referrals, respectively in each category). Early- and late-stage cancers had similar median waiting times from referral to diagnosis. Age over 65 years and the blood-loss indications — a positive faecal occult blood test or iron deficiency/anaemia — were predictors of an increased risk of carcinoma at colonoscopy.Conclusions: Waiting time for colonoscopy was not associated with an increase in the proportion of late-stage cancers diagnosed. Age over 65 years and evidence of blood loss increased the likelihood of a cancer diagnosis.

Charlie H Viiala MB BS, FRACP · Kevin W Tang MB BS · Ian C Lawrance MB BS, FRACP, PhD · Kevin Murray BSc, MSc · John K Olynyk BMedSc, MB BS, FRACP, MD

Objective: To describe the process of colorectal cancer diagnosis in Queensland, and to determine factors associated with time to diagnosis.Design, setting and participants: Cross-sectional study of 1996 patients with colorectal cancer recruited through the Queensland Cancer Registry. Data were collected by computer-assisted telephone interview between May 2003 and August 2005.Main outcome measures: Time to diagnosis: pre-presentation time (time from first noticing a symptom to first presenting to a doctor); and post-presentation time (time between the first presentation and diagnosis).Results: Most patients (90%) had experienced symptoms before being diagnosed with colorectal cancer; only 2% of patients were diagnosed by faecal occult blood testing. Older participants and those who experienced abdominal pain had the shortest time from symptom onset to their first doctor consultation, while participants with a change in bowel habit, or rectal bleeding, and those without private health insurance tended to wait longer to see a doctor. Participants who experienced abdominal pain were diagnosed more quickly, whereas those who experienced a change in bowel habit, women, and those without private health insurance experienced a longer time to diagnosis.Conclusions: The strong association between not having health insurance and longer post-presentation times is concerning. The other hypothesised predictors of time to diagnosis were not as strongly associated as we anticipated.

Brigid M Lynch BSc, MScsComm · Peter Baade PhD · Lin Fritschi MB BS, PhD · Barbara Leggett MB BS, MD · Neville Owen PhD · Kenneth Pakenham PhD, MAP(Clin) · Beth Newman PhD · Joanne F Aitken PhD

Objective: To investigate predictors of evidence-based surgical care in a population-based sample of patients with newly diagnosed colorectal cancer.Design, patients and setting: Prospective audit of all new patients with colorectal cancer reported to the New South Wales Central Cancer Registry between 1 February 2000 and 31 January 2001.Main outcome measures: Concordance with seven guidelines from the 1999 Australian evidence-based guidelines for colorectal cancer; predictors of guideline concordance; the mean proportion of relevant guidelines followed for individual patients.Results: Questionnaires were received for 3095 patients (91.6%). Between 0 and 100% of relevant guidelines were followed for individual patients (median, 67%). Concordance with individual guidelines varied considerably. Patient age independently predicted non-concordance with guidelines for adjuvant therapy and preoperative radiotherapy. Adjuvant chemotherapy was more likely if a patient with node-positive colon cancer was treated in a metropolitan hospital or by a general surgeon. Surgeons with a high caseload or specialty in colorectal cancer were more likely to perform colonic pouch reconstruction, prescribe thromboembolism or antibiotic prophylaxis, and were less likely to refer patients with high-risk rectal cancer for adjuvant radiotherapy. Bowel preparation was less likely among older patients and in high-caseload hospitals.Conclusion: Effective strategies to fully implement national colorectal cancer guidelines are needed. In particular, increasing the use of appropriate adjuvant therapy should be a priority, especially among older people.

Jane M Young MPH, PhD, FAFPHM · David C Leong MB BS, FRACP · Katie Armstrong BAppSc(HIM) · Dianne O’Connell BMaths(Hons), PhD · Bruce K Armstrong DPhil, FRACP, FAFPHM · Allan D Spigelman FRACS, FRCS, MD · Stephen Ackland MB BS, FRACP · Pierre Chapuis MB BS, DS, FRACS · Andrew B Kneebone MB BS, FRANZCR · Michael J Solomon MB BCh(Hons), MSc(ClinEpid), FRACS

Objective: To explore the ways that patients and health professionals communicate about intimate and sexual changes in cancer and palliative care settings.Design: A qualitative study using a three-stage reflexive-inquiry approach, with semi-structured, participant interviews (n = 82); textual analysis of national and international cancer and palliative care clinical practice guidelines (n = 33); and participant feedback at 15 educational forums for cancer patients or health professionals.Setting: A large Australian public teaching hospital between 2002 and 2005.Participants: 50 patients diagnosed with cancer, and 32 health professionals who had worked in cancer and/or palliative care for a minimum of 12 months.Main outcome measures: Communication about intimacy and sexuality: patients’ needs and experiences and health professionals’ attitudes and experiences.Results: There were mismatched expectations between patients and health professionals and unmet patient needs in communication about sexuality and intimacy. Most patients sought information, support and practical strategies about how to live with intimate and sexual changes after treatment for cancer, even if their cancer type did not affect fertility or sexual performance. In contrast, many health professionals assumed that patients shared their professional focus on combating the disease, irrespective of the emotional and physical costs to the patient. Health professionals overwhelmingly limited their understanding of patient sexuality to fertility, contraception, menopausal or erectile status. Many stereotypical assumptions were made about patient sexuality, based on age, sex, diagnosis, culture, and partnership status. There was a relationship between providing patient-centred communication about intimacy and sexuality and health professionals’ understanding of their own attitudes and beliefs.Conclusion: Resources are needed to help health professionals engage in an exploration of their own definitions of intimacy and sexuality and understand how these affect interactions with patients with cancer.

Amanda J Hordern PhD · Annette F Street PhD

To the Editor: Sanderson et al provide an interesting viewpoint about how the community, including medical practitioners, have embraced complementary and alternative medicine (CAM).1 However, if we were reviewing this article for publication, we would ask the authors to: make a valid distinction between those complementary and alternative therapies promoted as curative versus those considered palliative; define how they decided which therapies belong to one or other side of the arbitrary CAM boundary; review and justify the boundaries for the “therapeutic footprint” in a more evidence-based and rigorous way; locate specific therapies inside the footprint; locate where chemotherapy lies within the footprint, in light of the recent review showing, for the vast majority of adult malignancies, its marginal survival benefits considering its high costs, both monetary and healthwise;2 emphasise that there are relatively few recorded adverse events for CAM compared with conventional cancer care (Therapeutic Goods Administration Medicine Summary reports 2003, 2004, 2005 — Dr K Mackay, Acting Director, Adverse Drug Reactions Unit, TGA, personal communication); and vigorously question the marketing of conventional medicines, such as trastuzumab (Herceptin, Roche), to vulnerable patients and an uncritical public when the evidence suggests huge expense and little, if any, survival benefit.3 Perhaps a distinction also needs to be made between CAM therapies, many of which provide proven symptomatic relief, and those lifestyle interventions, such as exercise,4 dietary change,5 and social support, which provide symptomatic relief and may also confer a survival benefit. It does not serve the profession well when many cancer patients and their carers have to go outside the medical system to access information, advice and therapies which they should have easy access to within the system. In fact, we might even question how helpful these arbitrary boundaries are when all that patients and doctors want is to use what works and what is safe.

Craig S Hassed · Vicki Kotsirilos · Marie Pirotta · Avni Sali

In reply: We would like to thank Hassed and colleagues for their comments on the “therapeutic footprint” and their questions about locating specific therapies within the model. While it was outside the scope of our article to critically analyse different treatments using the model (as benefits and risks will vary from patient to patient), we would like to direct Hassed et al to a more detailed consideration of the risks and benefits of chemotherapy.1 We do not see our model as a tool to categorise or economically appraise specific treatments, but rather as one to help conceptualise the key issues to be considered when proposing treatment — the evidence for benefits and risks, contextualised according to treatment goals. The model provides a basis for comparison, taking us beyond arbitrary and unhelpful arguments about the distinctions between complementary and alternative therapies and their boundaries. We hope that the model will encourage evaluation of evidence for all therapies and support critical evaluation not only of drugs, but also lifestyle interventions that may benefit patients. The primary or essential purpose of the model is to encourage the posing of questions like those articulated by Hassed and colleagues to any therapist — whether they identify as medical, complementary or alternative.

Christine R Sanderson · Bogda Koczwara · David C Currow

To the Editor: Primary care skin cancer clinics continue to receive negative publicity. We have previously reported on the workload profile of one network of clinics.1 We report here the profile of clinical activity of the four MoleScan skin cancer clinics situated on the Sunshine Coast, Queensland. Between them, these clinics have been open for a total of 22 years, ranging from 2 years to nearly 9 years of operation. MoleScan is a service company with clinics across Australia. Doctors are employed as subcontractors and are provided with digital dermascopes. The clinics do not have dedicated day surgery facilities, and surgical procedures are conducted in the consulting rooms (http://www.molescan.com.au). Using Medicare Benefits Schedule item number billing data (as previously reported1), we calculated the number of consultations, biopsies, excised lesions (benign, non-melanoma skin cancers [NMSCs] and melanoma), surgical repairs, non-surgical treatment of skin cancers, and non-surgical treatment of other skin lesions. We also estimated the number needed to treat (NNT), defined as the number of benign lesions removed per melanoma. There were 98 276 consultations at the four clinics during the 22 years of operation (Box). In all, 14 982 skin cancers were treated: 395 melanomas and 7468 NMSCs by surgical excision, and 7119 NMSCs by non-surgical methods. The estimated NNT was 22.5. Of the 16 962 lesions excised, 11% (1812) were repaired by a skin flap, 68% (1226) of which were simple flaps. Our previous report, on a different network of clinics,1 showed a different pattern of surgical repairs: 33% (2651) of the 8055 lesions excised were repaired by a skin flap, 45% (1187) of which were simple flaps. Clearly, the clinical practices of these two clinic networks vary. Another area of apparent difference between the two clinic groups is the NNT — 22.5 reported here, compared with 28.6 from the other network.1 The lower NNT in these MoleScan clinics may result from the use of digital dermoscopy, but this requires further study. These early findings from our analyses of MoleScan data highlight the dangers of generalising about the activities of primary care skin cancer clinics from one dataset. Workload profiles of different clinical services may vary markedly, and the widely expressed concern about large numbers of inappropriate surgical repairs may not be warranted. Activities billed at four MoleScan skin cancer clinics on the Sunshine Coast, Queensland, over a total of 22 years of operation * Eyelid, nose, ear, lip, neck, hand, digit or genitals.

Deborah A Askew · David Wilkinson · Gordon L Patrick

To the Editor: We read with interest the article by Couper et al on the psychosocial impact of prostate cancer (PCA) on patients and their female partners.1 We agree that involvement of partners in the research pro-cess is pivotal to understanding the relational dimension of how PCA is both understood and approached by men and their partners.2 However, this could be extended to consider the unique experiences of gay men diagnosed with PCA and their partners. Heteronormative viewpoints are commonplace in PCA research. This bias is unfortunate, as there is a 28% possibility that one of the men in a gay relationship will develop PCA over the course of his lifetime.3 While it is probable that gay men and their partners have some of the same concerns regarding PCA as heterosexual couples, there are also unique concerns that are specific to gay men and their partners. Such considerations may include (but are not limited to): the prostate gland as a site of sexual pleasure and the associated implications of being able to engage in penetrative anal sex after prostate surgery;4 homophobia and/or disregard for sexuality within the health care system5 when being diagnosed with and treated for PCA; and the impact of polygamous (open) relationships and the ambiguous position of gay partners having to care for their mates.4 At this stage, the above concerns are purely speculative, as there is a paucity of literature on gay men and PCA.4,6 We believe future research on the psychosocial impacts of PCA should consider the experiences and special concerns of gay men with PCA, as well as those of their partners.

James A Smith · Shaun M Filiault · Murray J Drummond · Robert J Knapman

In reply: We thank Smith et al for their acknowledgement of the importance of the relational dimension to understanding how prostate cancer (PCA) is understood and approached by men and their partners. The psychosocial implications of prostate cancer for same-sex couples are important and need specific investigation. However, there are methodological difficulties in attempting to quantify the impact of PCA on same-sex couples and in comparing their experience with other couples. In our review of the literature,1 we discovered that where previous researchers had included same-sex partners in their studies, insufficient numbers were recruited for meaningful quantitative statistical comparisons. For example, Perez and colleagues,2 Neese and colleagues3 and Davison and colleagues4 each recruited only one same-sex couple into their studies of 134, 164 and 74 couples, respectively. We believe that a qualitative approach is needed, specifically seeking out and examining the experiences of a group of same-sex couples and comparing and contrasting their experiences with those of a group of male–female couples. This is an approach we are considering in future studies to help us develop and refine an effective but broadly applicable couple-focused psychosocial intervention for PCA.

Jeremy W Couper

Expert guidance is needed to balance the benefits and risks of sun exposure Vitamin D (defined in this article as serum 25-hydroxy-vitamin D) is largely obtained through the effect of sunlight on the skin. Vitamin D plays an undeniably important role in maintenance of bone health, preventing the development of rickets and osteomalacia. However, there has been increasing recent media attention given to research findings that suggest other possible benefits of vitamin D, such as prevention of certain cancers or multiple sclerosis.1,2 In the first 6 months of 2006, seven of 124 daily updates on “cancer-related news” (6%) monitored by The Cancer Council Australia featured at least one item on the importance of sun exposure for obtaining sufficient vitamin D to prevent chronic diseases. Given that the primary source of health information for most Australians is the media,3 such reports have the potential to change attitudes and behaviours to sun exposure. Some commentators have compared doctors with sherpas who need to guide their patients through an increasingly complex medical world.4 The “vitamin D story”, in which sun exposure appears to both cause cancer and prevent cancer, is one example where health consumers will need the guidance of health professionals in making an informed decision. Since the 1980s, the “Slip! Slop! Slap!” and then the “SunSmart” campaigns have sought to reduce population exposure to sunlight with the ultimate aim of reducing the burden of skin cancer in Australia.5 The challenge, given current levels of evidence, is to provide a public health message that ensures skin cancer risk is minimised while taking a precautionary approach to the possible harms of insufficient circulating levels of vitamin D. Several agencies have initiated conferences and meetings within the past 2 years, resulting in articles recommending changes to current sun-protection messages,6-8 and this year, the first issue of the journal Progress in Biophysics and Molecular Biology was wholly devoted to ultraviolet (UV) radiation exposure guidance. In Australia, a position statement on the risks and benefits of sun exposure was approved in 2005 by the Australian and New Zealand Bone and Mineral Society, Osteoporosis Australia, the Australasian College of Dermatologists and The Cancer Council Australia. The statement’s intention is to guide health professionals in giving information to the public on sun-protection behaviour. Four recommendations were made, and are summarised in the Box.9 Given the uncertainty about whether the subgroups within the population with the highest prevalence of vitamin D deficiency (the frail and elderly, people who cover themselves with clothing for cultural or religious reasons, those with dark skin pigmentation, those with mental illnesses) would benefit from a relaxation of sun-protection messages, each recommendation should be a starting point for further research. For example, considering the first recommendation (Box), the few studies available to date mostly indicate that, while most people are aware of the UV index, very few adjust their sun-protection behaviour accordingly.10-13 We need to determine ways to ensure that the UV index is routinely reported in weather forecasts in both summer and winter, and to increase public understanding of the implications of the UV index for sun-exposure behaviour. Additionally, it is likely that the association between the UV index and vitamin D production is not linear, and this needs to be explored in greater detail.14 Will the second recommendation (Box) lead to a more relaxed attitude towards sun protection in summer in southern states? Basal cell carcinomas and squamous cell carcinomas most commonly occur on the habitually sun-exposed skin sites.15 While these skin cancers are rarely fatal, their treatment can require surgical or destructive intervention and cause considerable morbidity.16 An unintended consequence of the second recommendation might be to increase incidental sun exposure of the arms and face and hence the incidence of skin cancer. Thus, the way this recommendation should be translated into a public health message needs careful consideration. For the third recommendation (Box), previous research has shown that people find it difficult to correctly assess their personal risk for skin cancer,17,18 and clinicians may need to help patients identify their risk. With regard to the fourth recommendation (Box), even though there is mandatory fortification of margarine in Australia, this is unlikely to achieve sufficient oral intake of vitamin D, especially among those most in need, and further supplementation may be necessary.19 The acceptability and effect of fortification and supplementation among at-risk groups still requires testing, and other food sources suitable for fortification need to be identified. At present, these complex recommendations are not being widely promoted to the general public, and further evidence on how to best communicate them is required, particularly in light of the media interest. Anecdotal evidence from the Queensland Cancer Fund suggests that the number of callers to their Helpline seeking advice about correct sun-protection behaviour is increasing. Further, unpublished data from a population-based survey conducted by the Queensland Cancer Fund in 2004 indicates that 837 of 5611 participants (15%) agreed with the statement, “If I regularly protect myself from the sun, I am in danger of not getting enough vitamin D”.20 These people were more likely to deliberately sunbathe than those who did not agree with this statement (odds ratio, 1.65; 95% CI, 1.30–2.09).20 Assuming that the association between various chronic diseases and vitamin D can be unequivocally established, and that the appropriate vitamin D level and the UV radiation dose required to obtain it can be quantified — which is by no means certain — it still may not be possible to provide a single message about “healthy” sun exposure appropriate for the whole of Australia, a continent that spans more than 35 degrees of latitude. It has been estimated that only 6–12 minutes of winter sun exposure three to four times a week may be sufficient to produce “healthy” levels of vitamin D in Brisbane, compared with 51 minutes in Melbourne.21 Many factors in addition to latitude (age, skin type, sun-exposure habits, other skin cancer risk factors, photoprotection, body mass index, food choices, amount of physical exercise, liver and renal health, environmental conditions such as smog, season, ozone) contribute to either people’s risk of skin cancer or their ability to synthesise vitamin D, or both. More research is needed to better understand the photobiology of vitamin D formation in the skin, and the precise effect of UV radiation on vitamin D synthesis within various subgroups of the population. We don’t yet know the minimum amount of sunlight needed to maintain healthy bones (let alone prevent internal cancers or chronic diseases, if indeed these benefits can be realised), nor whether these effects may not be better obtained through supplements. It is unlikely that the daily requirement for vitamin D could be obtained from foods fortified with vitamin D alone.22 A meta-analysis of randomised trials of vitamin D supplementation found that daily doses of 700–800 IU (17.5–20.0 μg) reduced the incidence of fractures, but lower doses did not.23 Even after the answers to these fundamental research questions are known, translating these complex messages to the Australian public effectively will remain a challenge. In the interim, the effect of current campaigns and media reports about vitamin D on sun-protective behaviours and sunburn rates should be monitored carefully, sun-safe practices should be encouraged and supplements used where necessary until we increase our basic understanding of the relationships between chronic disease, vitamin D and sunlight. Sun exposure is the primary cause of skin cancer. If sun exposure and sunburn were to increase as a result of concern about the requirement for vitamin D, several decades of effective public health promotion to reduce the incidence of the most common cancer in Australia would be jeopardised. Summary of the risks and benefit of sun exposure position statement* Sun protection is usually required if the ultraviolet (UV) index is 3 and above (and people are advised to check the forecast UV index in their local area); Most people achieve adequate vitamin D levels through incidental sun exposure, but people living in the southern Australian states in winter may need 2–3 hours of sun exposure on the hands, arms and face each week; Some people are at high risk of developing skin cancer and need more rigorous sun protection than the general population; Some subgroups of the population, such as the frail and elderly, and people who cover most of their body with clothing for cultural reasons may need to consult their doctor to have their Vitamin D status investigated and supplemented if necessary. * Modified from the full statement.9

Monika Janda MPhil, PhD · Michael G Kimlin MAppSc, PhD · David C Whiteman FAFPHM, PhD · Joanne F Aitken MSc, PhD · Rachel E Neale BVSc, PhD

Radiograph showing diffuse dense pleural thickening encasing the left hemithorax, multiple metastatic nodules in the left lung, and a solitary deposit in the right mid zone. A 21-year-old man with a high-grade osteoblastic sarcoma of the tibia had a tumour resection and adjuvant chemotherapy. Eight months later, he became dyspnoeic and a radiograph showed a large left-sided pleural effusion and a nodule in the right mid zone. Calcified pleural metastases were confirmed on biopsy, and talc pleurodesis was performed. High-dose methotrexate was commenced, but 2 months later a chest radiograph showed marked calcification of the pleura and pulmonary metastases on the left side (Figure). The right pulmonary nodule had increased in size and the patient’s serum alkaline phosphatase level had risen to 4459 U/L (reference range, 30–130 U/L). A trial of ifosfamide transiently reduced the alkaline phosphatase level. The patient died 4 months later.

Georgina Long PhD, MB BS · Martin H Tattersall MD, MSc

Moving beyond the uncertainties of risk, and limited, often difficult, preservation options, will require consensus and collaborative research The remarkable cure rates achieved in childhood cancer mean that large numbers of survivors are currently among the young adult population. However, the treatment that has achieved this success may have adverse effects in many organ systems, including the reproductive organs. These adverse effects may result from the impact of cytotoxic chemotherapy (alkylating drugs such as cyclophosphamide, iphosphamide, procarbazine and busulfan, in particular) on gametogenesis, from radiation damage to the gonads, or from radiation delivered to the hypothalamic–pituitary axis. To preserve fertility, it is necessary to determine the risk of fertility impairment before instituting cancer therapy. Predicting the impact of treatment on reproductive function in individual children based on expected exposures is notoriously unreliable. Current tools, both biochemical and biophysical, are unsuitable for assessing actual reproductive impacts in prepubertal and peripubertal children. Even when pubertal onset and progression is apparently normal, the integrity of gametes may have been compromised. A case–control study of 33 male survivors of childhood cancer showed that only a third had normal semen quality, and even in those who were not azoospermic, there were significant differences from normal controls. Seven of 11 azoospermic young adults were prepubertal at treatment, implying that the prepubertal state does not afford protection.1 Similarly, a study of young adult female survivors treated in childhood, all of whom had regular menses or had a history of normal menses if they were using combined oral contraception, revealed partial reduction in ovarian reserve as shown by elevated follicle-stimulating hormone (FSH) levels, lower anti-Mullerian hormone levels and smaller ovary size on ultrasound in those with spontaneous menstruation, and failure to elevate inhibin B levels in response to FSH stimulation in those using combined oral contraception.2 On the other hand, pregnancies have been noted in individuals predicted to be sterilised by their exposures to cancer therapies. The treatment protocols applicable to a child’s particular diagnosis may suggest higher risk. Those exposed to dose-intensive regimes of cyclophosphamide3 and other alkylators, particularly those with Hodgkin’s lymphoma treated with MOPP (mustine hydrochloride [nitrogen mustard], Oncovin [vincristine], procarbazine and prednisone) and other alkylator-intense regimens, including those with metastatic sarcomas, or bone marrow transplantation, are at increased risk. Others at higher risk are those who need pelvic or testicular irradiation, or total body irradiation before marrow transplantation. At the other end of the spectrum, children about to commence therapy on low-intensity protocols, such as those used for low-stage Wilms’ tumour or acute lymphoblastic leukaemia, are at minimal risk of infertility. However, a substantial proportion of children beginning treatment fall into an intermediate risk category for which prediction is fraught with inaccuracy. The cut-off of 7.5 g/m2 of cyclophosphamide recommended by the Children’s Oncology Group as the exposure level to trigger screening for fertility is a reasonable approximation of elevated risk, but not a reliable predictor of outcome at the beginning of therapy. Given the uncertainty of predicting fertility outcomes, what options exist for preserving fertility in children facing cancer therapy, and how should parents and patients be counselled? Cryopreservation of semen and subsequent in-vitro fertilisation is the only standard option for postpubertal males, and spermarche is the watershed around which options for boys are defined. Spermarche typically is an early to mid-pubertal event and occurs before the ability to achieve ejaculation.4 In the mature adolescent, semen is usually obtained by masturbation, with electrostimulation or vibratory stimulation as alternatives (the latter two may be applicable in peripubertal boys). However, the rate at which viable samples are obtained is highly variable. These adolescents are often sick as well as embarrassed and uncomfortable. One study of 62 attempts by adolescents to bank sperm before therapy resulted in totally normal semen in only four.5 Adolescents may be more successful if unaccompanied by parents.6 The advent of intracytoplasmic sperm injection (ICSI) enables in-vitro fertilisation of ova with even single sperm and so, despite the low yield rate, semen cryopreservation should be encouraged — as appears to be the case in the survey of practice in Australia and New Zealand by Heath and Stern in this issue of the Journal.7 Whether ICSI will increase the incidence of abnormalities in the offspring of cancer survivors remains to be seen — the incidence of abnormalities in offspring of cancer survivors conceived by natural means is not elevated.8,9 However, ICSI may bypass the normal protective mechanisms which terminate abnormal embryos. In adult men unable to produce semen for cryopreservation, harvesting of testicular sperm has been undertaken, either from testicular biopsy or percutaneous aspiration. However, in the presence of circulating cancer cells, breaching the blood–testicular barrier may pose the risk of testicular cancer recurrence analogous to the increased rate of central nervous system leukaemia after traumatic lumbar puncture. Of interest, even when sperm is banked, studies in adults suggest that a small proportion of men (10%–30%) retrieve and use the banked specimen.10 For prepubertal males, no current routine option exists. Approaches that may develop include testicular tissue cryo-preservation, and germ cell cryopreservation and autografting. Both are entirely experimental at this time.11 For female patients, the options are more limited. For mature women, oocytes can be harvested and fertilised, and resulting embryos preserved. However, this requires at least 2 weeks of hormonal preparation (daily injections of FSH), and an existing sperm source. Similarly, oocytes can be preserved and subsequently fertilised when a sperm donor is available, although success rates are lower.12 Neither technique is applicable to children or adolescents. As ovarian tissue contains significant numbers of primordial follicles in younger females, the harvesting and storage of ovarian tissue (preferably removed as ovarian cortical strips by laparoscopic techniques) before starting cancer therapy, with subsequent autotransplantation, is an experimental option. There is some evidence of successful restoration of hormone production and two reports of successful pregnancy.13,14 Which patients should be subjected to such invasive techniques needs clarification and consensus, and this procedure should only be undertaken under strict clinical trial conditions in centres with the necessary expertise. The risk of reintroducing cancer cells has not been accurately assessed, but is a real possibility.11 In the face of uncertainty and limited options, many of which are invasive, the paediatric oncology community has been slow to embrace routine and consistent counselling of families about fertility preservation options. Heath and Stern have demonstrated this hesitation among Australian and New Zealand oncologists,7 and similar results have been obtained in North America.15 To be able to provide effective counselling and improve pre-emptive interventions to preserve fertility, paediatric oncologists must inform themselves of the options for their patients, forge links with paediatric endocrinologists and reproductive medicine specialists, define at-risk patients by consensus, and commit to participating in research in this area — as they have already done so well in the context of defining best cancer treatments.

Mark L Greenberg MB ChB, FRCPC · Stacey L Urbach MD, MPH, FRCPC

Objective: To establish the extent to which sperm, oocyte and gonadal tissue collection and storage is offered to children newly diagnosed with cancer.Design, participants and setting: A cross-sectional survey of all paediatric oncology services in Australia and New Zealand (ANZ) in December 2005.Main outcome measures: Sperm, oocyte and gonadal tissue collection and storage practices at paediatric oncology services; comparisons with recently published North American practices and with current recommendations for best practice.Results: 12 of the 13 centres (92%) completed the survey. All centres offered sperm preservation, but only 10 (83%) offered oocyte/ovarian tissue preservation. Two centres were using gonadotrophin-releasing hormone analogues for fertility protection in postpubertal females. Five (42%) had offered fertility preservation to patients before the completion of their sexual development. All centres were more likely to offer sperm preservation than oocyte preservation for any given disease. The most common diseases for which conservation was offered were lymphomas and sarcomas. The anticipated cumulative dose at which centres elected to offer fertility preservation varied widely, both for the alkylator cyclophosphamide (any to 10 g/m2) and for abdominal/pelvic irradiation (any to 12 Gy) and spinal irradiation (any to 18 Gy). Fertility counselling was offered in a variety of settings by nine (75%) of the centres. Despite 11 centres (92%) agreeing that fertility preservation guidelines would be helpful, only two (17%) had guidelines in place.Conclusions: There are inconsistencies in the indications for and methods of gamete conservation in paediatric oncology centres throughout ANZ. Variations in practice on a background of unresolved medical, legal and ethical issues suggest the development of guidelines would be helpful.

John A Heath PhD, FRACP · Catherine J Stern MB BS, FRACOG

To the Editor: A young man, a minor when sentenced in Sydney, was diagnosed with lymphoma soon after incarceration. Appropriate treatment was initiated, including pretreatment collection and storage of his semen. A local newspaper report that his sperm was collected and stored at taxpayers’ expense prompted outrage in some sections of the community. In response, the New South Wales Government drafted the Corrective Services Legislation Amendment Bill 2006, which would make it a crime for an individual imprisoned or awaiting sentencing for a “serious indictable offence”, such as homicide, rape or terrorism to store “reproductive material” (semen or ova).1 It is routine (many would say mandatory) for men of reproductive age who are about to undergo therapy for cancer to be offered the option to store semen. Without this option, male cancer survivors might be unable to father their own offspring. There is no current routine technology for storing unfertilised ova. In current practice for male prisoners, semen is stored before commencing treatment for cancers or similar conditions that may induce temporary or permanent infertility. This is the accepted standard of care, offered before such treatment to men who may not have completed their families. It is not current practice in NSW to store prisoners’ semen in any other circumstances. The proposed Bill will discriminate against prisoners in the quality and costs of their health care. Members of our community who require chemotherapy for cancer are offered collection and storage of their semen, provided free of charge by several public services in NSW. Under the proposed Bill, prisoners are required to pay storage fees during their imprisonment, even if their sperm were placed in storage before their incarceration. Discriminating against certain prisoners by demanding payment for otherwise free services could be seen as a “cruel and unusual punishment”. The NSW Legislative Assembly passed the Bill on 25 May 2006. Medical, legal and human rights organisations, and individuals expressed concern to parliamentarians. In the Legislative Council on 7 June 2006, a majority vote referred the Bill to the General Purposes Standing Committee No. 3. This Committee has received submissions and will provide recommendations as to how the Bill should proceed. If passed into law, the Bill would breach the principle of equivalence of health care for prisoners. The Australian Medical Association position statement on the Health care of prisoners and detainees states: “The duty of medical practitioners to treat all patients professionally with respect for their human dignity and privacy applies equally to the care of those detained in prison, whether convicted or on remand, irrespective of the reason for their incarceration.”2 I argue that the Bill implies an intention to rid society of “criminal seed” and begins a move towards eugenics. If our society really accepts the idea that inmates of correctional facilities may one day return to a full and productive life, then it is unreasonable to deny them the possibility of having their own children because they developed a serious cancer. If this legislation is passed, a discriminatory practice of medicine according to convict status will be enshrined in NSW law.

John E J Rasko