MJA
MJA

    Outpatient heart failure programs: time for a new standard

    Amera Halabi and Derek P Chew
    Med J Aust 2018; 208 (11): . || doi: 10.5694/mja18.00329
    Published online: 18 June 2018

    Effective ambulatory services and community heart failure care may mitigate its impact on our health care system

    Heart failure imposes a significant burden on the Australian health care system. Driven by the increasing number of patients diagnosed each year, repeated hospitalisations and long inpatient stays result in substantial morbidity and costs to the health care system.1

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      Burnout in the medical profession: not a rite of passage

      Michael Baigent and Ruth Baigent
      Med J Aust 2018; 208 (11): . || doi: 10.5694/mja17.00891
      Published online: 18 June 2018

      Establishing mentally healthy workplaces will reduce the risk of burnout

      It is an attention-demanding tragedy when doctors’ deaths are attributed to their work, which, after all, is in the service of others. “Epidemic”, “crisis” and “urgent need” are words accompanying discussions of burnout and doctor suicides. Yet, despite this bombardment, there has been no sustained approach to achieve an effective national response. Recently, responding to calls for action, the Victorian government launched a workplace mental health strategy and the New South Wales government held a junior doctor wellbeing forum. Some colleges and medical organisations have websites, forums, action plans, conferences and seminars on doctors’ mental health. Doctors develop mental illness for the same reasons as any other person. Yet burnout, which is a risk factor,1 is highly prevalent in doctors. Why not address the burnout? Who should address it?


      • 1 Flinders University, Adelaide, SA
      • 2 Norwood General and Family Practice, Adelaide, SA


      Competing interests:

      Michael Baigent serves on the Board of Directors for beyondblue, the national depression initiative, a not-for-profit organisation.

      • 1. Salvagioni DAJ, Melanda FN, Mesas AE, et al. Physical, psychological and occupational consequences of job burnout: a systematic review of prospective studies. PLoS ONE 2017; 12: e0185781.
      • 2. Freudenberger HJ. The staff burnout syndrome in alternative institutions. Psychother Theory Res Pract 1975; 12: 72-83.
      • 3. Maslach C, Schaufeli WB, Leiter MP. Job burnout. Annu Rev Psychol 2001; 52: 397-422.
      • 4. Maslach C. What have we learned about burnout and health? Psychol Health 2001; 16: 607-611.
      • 5. Hallberg UE, Sverke M. Construct validity of the Maslach Burnout Inventory: two Swedish health care samples. Eur J Psychol Assess 2004; 20: 320-338.
      • 6. Maslach C, Leiter MP. New insights into burnout and health care: strategies for improving civility and alleviating burnout. Med Teach 2017; 39: 160-163.
      • 7. Shanafelt TD, Boone S, Tan L, et al. Burnout and satisfaction with work-life balance among US physicians relative to the general US population. Arch Intern Med 2012; 172: 1377-1385.
      • 8. Imo UO. Burnout and psychiatric morbidity among doctors in the UK: a systematic literature review of prevalence and associated factors. Psychiatrist 2017; 41: 197-204.
      • 9. beyondblue. National mental health survey of doctors and medical students. Oct 2013. https://www.beyondblue.org.au/docs/default-source/research-project-files/bl1132-report–-nmhdmss-full-report_web (viewed Apr 2018).
      • 10. Kwarta P, Pietrzak J, Miśkowiec D, et al. Personality traits and styles of coping with stress in physicians. Pol Merkur Lekarski 2016; 40: 301-307.
      • 11. McManus IC, Keeling A, Paice E. Stress, burnout and doctors’ attitudes to work are determined by personality and learning style: a twelve year longitudinal study of UK medical graduates. BMC Medicine 2004; 2: 29.
      • 12. Shanafelt TD, Oreskovich MR, Dyrbye LN, et al. Avoiding burnout: the personal health habits and wellness practices of US surgeons. Ann Surg 2012; 255: 625-633.
      • 13. Halliday L, Walker A, Vig S, et al. Grit and burnout in UK doctors: a cross-sectional study across specialties and stages of training. Postgrad Med J 2017; 93: 389-394.
      • 14. beyondblue. Developing a workplace mental health strategy: a how-to guide for health services. http://resources.beyondblue.org.au/prism/file?token=BL/1728 (viewed Apr 2018).
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        How antibiotic allergy labels may be harming our most vulnerable patients

        Jason A Trubiano, M Lindsay Grayson, Karin A Thursky, Elizabeth J Phillips and Monica A Slavin
        Med J Aust 2018; 208 (11): . || doi: 10.5694/mja17.00487
        Published online: 18 June 2018

        Antibiotic allergy testing programs will ensure that vulnerable patients receive appropriate antibiotic therapy

        Antibiotic allergy labels are accumulated by various mechanisms and are often incorrectly self-reported or recorded. Incorrect antibiotic allergy labels frequently persist in community and hospital medical records throughout patients’ health care journeys, either with the phenotype unverified by clinicians or recorded as unknown.1,2 Among a cohort of older Australian general medical inpatients, we identified that 25% had a mismatch between their reported and recorded antibiotic allergy.3 Further, as an additional source of incorrect antibiotic allergy labels, patients with a true immunological basis for antibiotic allergy, such as immediate (IgE-mediated) reactions, may lose reactivity over time.4 Incorrect antibiotic allergy labels often prevent the use of appropriate narrow spectrum penicillin and targeted antibiotic therapies in both community and hospital practice, frequently among the patients most in need.4,5


        • 1 Austin Health, Melbourne, VIC
        • 2 Peter MacCallum Cancer Centre and National Centre for Infections in Cancer, Melbourne, VIC
        • 3 University of Melbourne, Melbourne, VIC
        • 4 Royal Melbourne Hospital, Melbourne, VIC
        • 5 Institute for Immunology and Infectious Diseases, Murdoch University, Perth, WA


        Acknowledgements: 

        We thank Megan Crane for her significant contribution to the manuscript preparation and Michael Sutherland for establishing the Austin Health multidisciplinary antibiotic allergy testing service.

        Competing interests:

        No relevant disclosures.

        • 1. Trubiano JA, Chen C, Cheng AC, et al. Antimicrobial allergy ‘labels’ drive inappropriate antimicrobial prescribing: lessons for stewardship. J Antimicrob Chemother 2016; 71: 1715-1722.
        • 2. Knezevic B, Sprigg D, Seet J, et al. The revolving door: antibiotic allergy labelling in a tertiary care centre. Intern Med J 2016; 46: 1276-1283.
        • 3. Zhou L, Dhopeshwarkar N, Blumenthal KG, et al. Drug allergies documented in electronic health records of a large healthcare system. Allergy 2016; 71: 1305-1313.
        • 4. Trubiano JA, Leung VK, Chu MY, et al. The impact of antimicrobial allergy labels on antimicrobial usage in cancer patients. Antimicrob Resist Infect Control 2015; 4: 23.
        • 5. MacFadden DR, LaDelfa A, Leen J, et al. Impact of reported beta-lactam allergy on inpatient outcomes: a multicenter prospective cohort study. Clin Infect Dis 2016; 63: 904-910.
        • 6. Trubiano JA, Pai Mangalore R, Baey YW, et al. Old but not forgotten: Antibiotic allergies in General Medicine (the AGM Study). Med J Aust 2016; 204: 273. <MJA full text>
        • 7. Caubet JC, Frossard C, Fellay B, Eigenmann PA. Skin tests and in vitro allergy tests have a poor diagnostic value for benign skin rashes due to beta-lactams in children. Pediatr Allergy Immunol 2015; 26: 80-82.
        • 8. Vezir E, Dibek Misirlioglu E, Civelek E, et al. Direct oral provocation tests in non-immediate mild cutaneous reactions related to beta-lactam antibiotics. Pediatr Allergy Immunol 2016; 27: 50-54.
        • 9. Bourke J, Pavlos R, James I, Phillips E. Improving the effectiveness of penicillin allergy de-labeling. J Allergy Clin Immunol Pract 2015; 3: 365-334 e361.
        • 10. Trubiano JA, Worth LJ, Urbancic K, et al. Return to sender: the need to re-address patient antibiotic allergy labels in Australia and New Zealand. Intern Med J 2016; 46: 1311-1317.
        • 11. Macy E, Contreras R. Health care use and serious infection prevalence associated with penicillin “allergy” in hospitalized patients: a cohort study. J Allergy Clin Immunol 2014; 133: 790-796.
        • 12. Campagna JD, Bond MC, Schabelman E, Hayes BD. The use of cephalosporins in penicillin-allergic patients: a literature review. J Emerg Med 2012; 42: 612-620.
        • 13. Romano A, Gaeta F, Arribas Poves MF, Valluzzi RL. Cross-reactivity among beta-lactams. Curr Allergy Asthma Rep 2016; 16: 24.
        • 14. Kula B, Djordjevic G, Robinson JL. A systematic review: can one prescribe carbapenems to patients with IgE-mediated allergy to penicillins or cephalosporins? Clin Infect Dis 2014; 59: 1113-1122.
        • 15. Patriarca G, Schiavino D, Lombardo C, et al. Tolerability of aztreonam in patients with IgE-mediated hypersensitivity to beta-lactams. Int J Immunopathol Pharmacol 2008; 21: 375-379.
        • 16. Ressner RA, Gada SM, Banks TA. Antimicrobial stewardship and the allergist: reclaiming our antibiotic armamentarium. Clin Infect Dis 2016; 62: 400-401.
        • 17. Dellit TH, Owens RC, McGowan JE Jr, et al. Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America guidelines for developing an institutional program to enhance antimicrobial stewardship. Clin Infect Dis 2007; 44: 159-177.
        • 18. Schuts EC, Hulscher M, Mouton JW, et al. Current evidence on hospital antimicrobial stewardship objectives: a systematic review and meta-analysis. Lancet Infect Dis 2016; 16: 847-856.
        • 19. Barlam TF, Cosgrove SE, Abbo LM, et al. Implementing an antibiotic stewardship program: guidelines by the Infectious Diseases Society of America and the Society for Healthcare Epidemiology of America. Clin Infect Dis 2016; 62: e51-77.
        • 20. King EA, Challa S, Curtin P, Bielory L. Penicillin skin testing in hospitalized patients with beta-lactam allergies: effect on antibiotic selection and cost. Ann Allergy Asthma Immunol 2016; 117: 67-71.
        • 21. Trubiano JA, Thursky KA, Stewardson AJ, et al. Impact of an integrated antibiotic allergy testing program on antimicrobial stewardship: a multicenter evaluation. Clin Infect Dis 2017; 65: 166-174.
        • 22. Marwood J, Aguirrebarrena G, Kerr S, et al. De-labelling self-reported penicillin allergy within the emergency department through the use of skin tests and oral drug provocation testing. Emerg Med Australas 2017; 29: 509-515.
        • 23. Confino-Cohen R, Rosman Y, Meir-Shafrir K, et al. Oral challenge without skin testing safely excludes clinically significant delayed-onset penicillin hypersensitivity. J Allergy Clin Immunol Pract 2017; 5: 669-675.
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          Transcranial magnetic stimulation: an item number is justified

          Saxby Pridmore
          Med J Aust 2018; 208 (11): . || doi: 10.5694/mja17.00849
          Published online: 18 June 2018

          Evidence shows that transcranial magnetic stimulation is a safe and effective treatment for drug-resistant depression

          Depression is the leading cause of disability globally.1 The condition is painful for the patient (and may end in suicide), distressing for relatives and friends and challenging to clinicians. One-third of patients with depression do not respond to the first antidepressant medication, the likelihood of achieving remission diminishes with each additional medication, and one-third will not respond to any known medication.2


          • University of Tasmania, Hobart, TAS


          Correspondence: s.pridmore@utas.edu.au
          Competing interests:

          No relevant disclosures.

          • 1. World Health Organization The global burden of disease: 2004 update. Geneva: WHO; 2008. http://www.who.int/healthinfo/global_burden_disease/2004_report_update/en/index.html (viewed Aug 2017).
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          • 3. George MS, Wassermann EM, Williams WA, et al. Daily repetitive transcranial magnetic stimulation (rTMS) improves mood in depression. Neuroreport 1995; 6: 1853-1856.
          • 4. Lefaucheur J-P, André-Obadia N, Antal A, et al. Evidence-based guidelines on the therapeutic use of repetitive transcranial magnetic stimulation (rTMS). Clin Neurophysiol 2014; 125: 2150-2206.
          • 5. Loo CK, Mitchell PB, Corker VM, et al. Double-blind controlled investigation of bilateral prefrontal transcranial magnetic stimulation for the treatment of resistant major depression. Psychol Med 2003; 33: 33-40.
          • 6. Fitzgerald PB, Brown TL, Marston NA, et al. Transcranial magnetic stimulation in the treatment of depression: a double-blind, placebo-controlled trial. Arch Gen Psychiatry 2003; 60: 1002-1008.
          • 7. Milev R, Giacobbe P, Kennedy SH, et al. Canadian Network for Mood and Anxiety Treatments (CANMAT) 2016 clinical guidelines for the management of adults with major depressive disorder: section 4. Neurostimulation treatments. Can J Psychiatry 2016; 61: 561-575.
          • 8. Magnezi R, Aminov E, Shmuel D, et al. Comparison between neurostimulation techniques repetitive transcranial magnetic stimulation vs electroconvulsive therapy for the treatment of resistant depression: patient preference and cost-effectiveness. Patient Prefer Adherence 2016; 10: 1481-1487.
          • 9. Kozel FA, George MS, Simpson KN. Decision analysis of the cost-effectiveness of repetitive transcranial magnetic stimulation versus electroconvulsive therapy for treatment of nonpsychotic severe depression. CNS Spectr 2004; 9: 476-482.
          • 10. Zhao YJ, Tor PC, Khoo AL, et al. Cost-effectiveness modelling of repetitive transcranial magnetic stimulation compared to electroconvulsive therapy for treatment-resistant depression in Singapore. Neuromodulation 2017. doi:10.1111/ner.12723. [Epub ahead of print].
          • 11. Galletly CA, Clarke P, Carnell BL, Gill S. A clinical repetitive transcranial magnetic stimulation service: 6 years on. Aust N Z J Psychiatry 2014; 49: 1040-1047.
          • 12. McClintock SM, Reti IM, Carpenter LL, et al. Consensus recommendations for the clinical application of repetitive transcranial magnetic stimulation (rTMS) in the treatment of depression. J Clin Psychiatry 2018; 79: 16cs10905.
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            Australian standards of care and treatment guidelines for transgender and gender diverse children and adolescents

            Michelle M Telfer, Michelle A Tollit, Carmen C Pace and Ken C Pang
            Med J Aust 2018; 209 (3): . || doi: 10.5694/mja17.01044
            Published online: 18 June 2018

            Abstract

            Introduction: The Australian standards of care and treatment guidelines aim to maximise quality care provision to transgender and gender diverse (TGD) children and adolescents across Australia, while recognising the unique circumstances of providing such care to this population. Recommendations are made based on available empirical evidence and clinician consensus, and have been developed in consultation with Australian professionals from multiple disciplines working with the TGD population, TGD support organisations, as well as TGD children and adolescents and their families.

            Main recommendations: Recommendations include general principles for supporting TGD children and adolescents using an affirmative approach, separate guidelines for the care of pre-pubertal children and TGD adolescents, as well as discipline-based recommendations for mental health care, medical and surgical interventions, fertility preservation, and speech therapy.

            Changes in management as a result of this statement: Although published international treatment guidelines currently exist, challenges in accessing and providing TGD health care specific to Australia have not been addressed to date. In response to this, these are the first guidelines to be developed for TGD children and adolescents in Australia. These guidelines also move away from treatment recommendations based on chronological age, with recommended timing of medical transition and surgical interventions dependent on the adolescent’s capacity and competence to make informed decisions, duration of time on puberty suppression, coexisting mental health and medical issues, and existing family support.


            • 1 Royal Children's Hospital Melbourne, Melbourne, VIC
            • 2 Murdoch Children's Research Institute, Melbourne, VIC


            Correspondence: michelle.telfer@rch.org.au
            Competing interests:

            No relevant disclosures.

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              Lung transplantation in Australia, 1986–2018: more than 30 years in the making

              Miranda A Paraskeva, Kovi C Levin, Glen P Westall and Gregory I Snell
              Med J Aust 2018; 208 (10): . || doi: 10.5694/mja17.00909
              Published online: 4 June 2018

              Summary

               

              • Lung transplantation in Australia is 32 years old in 2018. From its early infancy in 1986, it continues to evolve and is internationally recognised as demonstrating world’s best practices in organ donation, utilisation and transplantation procedures.
              • Over the past decade, transplant numbers have increased substantially due to innovations in donor procurement, such as donation after circulatory death, the use of ex vivo lung perfusion, extended criteria and organ utilisation, with more than 200 lung transplants undertaken in Australia annually. Parallel to this, lung transplant outcomes have continued to improve.
              • While the management of lung transplant recipients is heavily dependent on a tertiary care paradigm, this model is well developed and has been extremely successful, with Australian outcomes exceeding those of the International Society for Heart and Lung Transplantation Registry at all time points.

               


              • 1 Alfred Hospital, Melbourne, VIC
              • 2 Monash University, Melbourne, VIC


              Correspondence: m.paraskeva@alfred.org.au
              Competing interests:

              No relevant disclosures

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              • 20. Singer JP, Diamond JM, Gries CJ, et al. Frailty phenotypes, disability, and outcomes in adult candidates for lung transplantation. Am J Respir Crit Care Med 2015; 192: 1325-1334.
              • 21. Wilson ME, Vakil AP, Kandel P, et al. Pretransplant frailty is associated with decreased survival after lung transplantation. J Heart Lung Transplant 2016; 35: 173-178.
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              • 23. Vajdic CM, McDonald SP, McCredie MR, et al. Cancer incidence before and after kidney transplantation. JAMA 2006; 296: 2823-2831.
              • 24. Mollberg NM, Farjah F, Howell E, et al. Impact of primary caregivers on long-term outcomes after lung transplantation. J Heart Lung Transplant 2015; 34: 59-64.
              • 25. Castleberry AW, Bishawi M, Worni M, et al. Medication nonadherence after lung transplantation in adult recipients. Ann Thorac Surg 2017; 103: 274-280.
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              • 28. Casswell GK, Pilcher DV, Martin RS, et al. Buying time: the use of extracorporeal membrane oxygenation as a bridge to lung transplantation in pediatric patients. Pediatr Transplant 2013; 17: E182-188.
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              • 46. Westall GP, Cristiano Y, Peleg A, et al. A study of QuantiFERON-CMV-directed CMV prophylaxis versus standard-of-care to reduce late CMV reactivation following lung transplantation. J Heart Lung Transplant 2017; 36: S200-S201.
              • 47. Langer D, Burtin C, Schepers L, et al. Exercise training after lung transplantation improves participation in daily activity: a randomized controlled trial. Am J Transplant 2012; 12: 1584-1592.
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                Clustered domestic residential aged care in Australia: fewer hospitalisations and better quality of life

                Suzanne M Dyer, Enwu Liu, Emmanuel S Gnanamanickam, Rachel Milte, Tiffany Easton, Stephanie L Harrison, Clare E Bradley, Julie Ratcliffe and Maria Crotty
                Med J Aust 2018; 208 (10): . || doi: 10.5694/mja17.00861
                Published online: 4 June 2018

                Abstract

                Objective: To compare the outcomes and costs of clustered domestic and standard Australian models of residential aged care.

                Design: Cross-sectional retrospective analysis of linked health service data, January 2015 – February 2016.

                Setting: 17 aged care facilities in four Australian states providing clustered (four) or standard Australian (13) models of residential aged care.

                Participants: People with or without cognitive impairment residing in a residential aged care facility (RACF) for at least 12 months, not in palliative care, with a family member willing to participate on their behalf if required. 901 residents were eligible; 541 consented to participation (24% self-consent, 76% proxy consent).

                Main outcome measures: Quality of life (measured with EQ-5D-5L); medical service use; health and residential care costs.

                Results: After adjusting for patient- and facility-level factors, individuals residing in clustered models of care had better quality of life (adjusted mean EQ-5D-5L score difference, 0.107; 95% CI, 0.028–0.186; P = 0.008), lower hospitalisation rates (adjusted rate ratio, 0.32; 95% CI, 0.13–0.79; P = 0.010), and lower emergency department presentation rates (adjusted rate ratio, 0.27; 95% CI, 0.14–0.53; P < 0.001) than residents of standard care facilities. Unadjusted facility running costs were similar for the two models, but, after adjusting for resident- and facility-related factors, it was estimated that overall there is a saving of $12 962 (2016 values; 95% CI, $11 092–14 831) per person per year in residential care costs.

                Conclusions: Clustered domestic models of residential care are associated with better quality of life and fewer hospitalisations for residents, without increasing whole of system costs.

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                • 1 Flinders University, Adelaide, SA
                • 2 NHMRC Cognitive Decline Partnership Centre, University of Sydney, Sydney, NSW
                • 3 Mary MacKillop Institute for Health Research, Melbourne, VIC
                • 4 Institute for Choice, University of South Australia Business School, Adelaide, SA
                • 5 South Australian Health and Medical Research Institute, Adelaide, SA


                Correspondence: sue.dyer@flinders.edu.au
                Acknowledgements: 

                We sincerely thank the INSPIRED study participants and their families for their participation and interest in the study. The assistance of facility staff, careworker researchers, facility pharmacists and data collectors in each state is gratefully acknowledged. We thank members of the study team - Anne Whitehouse, Angela Basso, Keren McKenna, Lua Perimal-Lewis, Wendy Shulver and Rebecca Bilton - for their input into study management, data collection, and data coordination. We acknowledge federal and state data custodians of the datasets used and the respective data linkage organisations, including the federal Departments of Veterans’ Affairs and Human Services, the Centre for Health Record Linkage (NSW Health), the Queensland Health Statistics Unit, the Data and Reporting Services Unit (SA Health, eHealth Systems), and the Western Australian Department of Health Data Linkage Branch.

                Competing interests:

                No relevant disclosures.

                • 1. Steering Committee for the Review of Government Service Provision. Report on government services 2017. Aged care services. Canberra: Productivity Commission, 2017. http://www.pc.gov.au/research/ongoing/report-on-government-services/2017/community-services/aged-care-services (viewed Jan 2018).
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                • 25. Kane RA, Lum TY, Cutler LJ, et al. Resident outcomes in small-house nursing homes: a longitudinal evaluation of the initial green house program. J Am Geriatr Soc 2007; 55: 832-839.
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                • 28. Grabowski DC, O’Malley AJ, Barhydt NR. The costs and potential savings associated with nursing home hospitalizations. Health Aff (Millwood) 2007; 26: 1753-1761.
                • 29. Jenkens R, Sult T, Lessell N, et al. Financial implications of the Green House model. Seniors and Housing Care Journal 2011; 19: 3-22.
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                  Low risk prostate cancer and an opportunity lost: more activity required in active surveillance

                  David P Smith and Gary A Wittert
                  Med J Aust 2018; 208 (10): . || doi: 10.5694/mja18.00209
                  Published online: 4 June 2018

                  Men who are being monitored may be more open to interventions for improving their general health and quality of life

                  Prostate cancer is the most frequently registered cancer in Australian men, with an estimated 17 729 new diagnoses in 2018.1 For the 25% who are diagnosed with low risk disease, active surveillance (AS) is now the recommended management strategy, as their cancer may never progress.2 Avoiding or at least postponing radical treatment reduces the quality of life risks associated with surgery or radiation therapy. However, there is no evidence-based consensus about the optimal approach to surveillance, and practices differ between countries with regard to the type, frequency, and sequence of follow-up.3 AS differs from “watchful waiting” in that it has a curative intent; watchful waiting involves less intense routine monitoring, intervening only when symptoms appear. One standard approach to AS recommends prostate-specific antigen (PSA) assessment every 3–6 months, a digital rectal examination at least once a year, and at least one biopsy within 12 months of diagnosis, followed by serial biopsy every 2–5 years.


                  • 1 Cancer Council NSW, Sydney, NSW
                  • 2 University of Adelaide, Adelaide, SA
                  • 3 Royal Adelaide Hospital, Adelaide, SA


                  Correspondence: dsmith@nswcc.org.au
                  Acknowledgements: 

                  David Smith and Gary Wittert are collaborators on an NHMRC Centre for Research Excellence in Prostate Cancer Survivorship (CRE-PCS) (1116334). David Smith was supported by a grant from Cancer Institute NSW (15/CDF/1‑10).

                  Competing interests:

                  David Smith is a member of the Prostate Cancer Outcomes Registry Australia and New Zealand (PCOR-ANZ) steering committee. Gary Wittert is Independent Chair of the Weight Management Council of Australia and has received research support from Weight Watchers.

                  • 1. Australian Institute of Health and Welfare. Cancer in Australia 2017 (AIHW Cat. No. CAN 100). Canberra: AIHW, 2017.
                  • 2. Chen RC, Rumble RB, Loblaw DA, et al. Active surveillance for the management of localized prostate cancer (Cancer Care Ontario Guideline): American Society of Clinical Oncology clinical practice guideline endorsement. J Clin Oncol 2016; 34: 2182-2190.
                  • 3. Ganz PA, Barry JM, Burke W, et al. National Institutes of Health State-of-the-Science Conference: role of active surveillance in the management of men with localized prostate cancer. Ann Intern Med 2012; 156: 591-595.
                  • 4. Evans MA, Millar JL, Earnest A, et al. Active surveillance of men with low risk prostate cancer: evidence from the Prostate Cancer Outcomes Registry–Victoria. Med J Aust 2018; 208: 439-443.
                  • 5. Egger SJ, Calopedos RJ, O’Connell DL, et al. Long-term psychological and quality-of-life effects of active surveillance and watchful waiting after diagnosis of low-risk localised prostate cancer. Eur Urol 2017; doi:10.1016/j.eururo.2017.08.013. [Epub ahead of print]
                  • 6. Sutton E, Hackshaw-McGeagh LE, Aning J, et al. The provision of dietary and physical activity advice for men diagnosed with prostate cancer: a qualitative study of the experiences and views of health care professionals, patients and partners. Cancer Causes Control 2017; 28: 319-329.
                  • 7. Daubenmier JJ, Weidner G, Marlin R, et al. Lifestyle and health-related quality of life of men with prostate cancer managed with active surveillance. Urology 2006; 67: 125-130.
                  • 8. Farris MS, Courneya KS, Kopciuk KA, et al. Post-diagnosis alcohol intake and prostate cancer survival: a population-based cohort study. Int J Cancer 2018; doi:10.1002/ijc.31307. [Epub ahead of print]
                  • 9. Peisch SF, Van Blarigan EL, Chan JM, et al. Prostate cancer progression and mortality: a review of diet and lifestyle factors. World J Urol 2017; 35: 867-874.
                  • 10. Adams R, Appleton S, Taylor A, et al. Are the ICSD-3 criteria for sleep apnoea syndrome too inclusive? Lancet Respir Med 2016; 4: e19-e20.
                  • 11. Emery JD, Shaw K, Williams B, et al. The role of primary care in early detection and follow-up of cancer. Nat Rev Clin Oncol 2014; 11: 38-48.
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                    Beyond PSA testing for prostate cancer

                    Doug Brooks, Ian N Olver and Adrian J Esterman
                    Med J Aust 2018; 208 (10): . || doi: 10.5694/mja18.00324
                    Published online: 4 June 2018

                    Better biomarkers are needed to ensure early and accurate detection and prognosis of prostate cancer

                    Prostate cancer is now the most common cancer diagnosed in men in Australia,1 and Australia has one of the highest incidence rates of prostate cancer in the world, with an estimated age-standardised rate of 119.2 per 100 000 men.2 Before 1960, the primary diagnostic test for prostate cancer was the prostatic acid phosphatase test. This was eventually replaced in the 1980s by the prostate-specific antigen (PSA) test.


                    • 1 University of South Australia Cancer Research Institute, Adelaide, SA
                    • 2 Australian Institute of Tropical Health and Medicine, James Cook University, Cairns, QLD


                    Correspondence: Doug.Brooks@unisa.edu.au
                    Competing interests:

                    Doug Brooks is developing cancer biomarkers for commercialisation with Envision Sciences Pty Ltd.

                    • 1. Australian Institute of Health and Welfare. Cancer in Australia 2017 (AIHW Cat. No. CAN 100; Cancer Series No. 101). Canberra: AIHW, 2017. https://www.aihw.gov.au/reports/cancer/cancer-in-australia-2017/contents/table-of-contents (viewed Mar 2018).
                    • 2. International Agency for Research on Cancer. GLOBOCAN 2012: estimated cancer incidence and mortality worldwide in 2012. http://globocan.iarc.fr (viewed Mar 2018).
                    • 3. Flocks RH, Urich VC, Patel CA, Opitz JM. Studies on the antigenic properties of prostatic tissue. 1. J Urol 1960; 84: 134-143.
                    • 4. Wang MC, Papsidero LD, Kuriyama M, et al. Prostate antigen: a new potential marker for prostatic cancer. Prostate 1981; 2: 89-96.
                    • 5. Kuriyama M, Wang MC, Lee CI, et al. Use of human prostate-specific antigen in monitoring prostate cancer. Cancer Res 1981; 41: 3874-3876.
                    • 6. Medscape. PSA test is misused, unreliable, says the antigen’s discoverer. Medscape Aug 08, 2014. https://www.medscape.com/viewarticle/828854 (viewed March 2018).
                    • 7. Harvey P, Basuita A, Endersby D, et al. A systematic review of the diagnostic accuracy of prostate-specific antigen. BMC Urol 2009; 9: 14.
                    • 8. Roddam AW, Duffy MJ, Hamdy FC, et al. Use of prostate-specific antigen (PSA) isoforms for the detection of prostate cancer in men with a PSA level of 2-10 ng/ml: systematic review and meta-analysis. Eur Urol 2005; 48: 386-399.
                    • 9. Thompson IM, Pauler DK, Goodman PJ, et al. Prevalence of prostate cancer among men with a prostate-specific antigen level ≤4.0 ng per milliliter. N Engl J Med 2004; 350: 2239-2246.
                    • 10. Catalona WJ, Richie JP, Goodman PJ, et al. Comparison of digital rectal examination and serum prostate specific antigen in the early detection of prostate cancer: results of a multicentre clinical trial of 6,630 men. J Urol 1994; 151: 1283-1290.
                    • 11. Pinsky PF, Porok PC, Yu K, et al. Extended mortality results for prostate cancer screening in the PLCO trial with a median 15 years follow-up. Cancer 2017; 123: 592-599.
                    • 12. Schröder FH, Hugosson J, Roobol MJ, et al. Screening and prostate cancer mortality: results of the European randomised study of screening for prostate cancer (ERSPC) investigators. Lancet 2014; 384: 2072-2035.
                    • 13. Tsodikov A, Gulati R, Heijnsdijk, et al. Reconciling the effects of screening on prostate cancer mortality in the ERSPC and PLCO Trials. Ann Intern Med 2017; 167: 449-455.
                    • 14. Australian Government Department of Health Standing Committee on Screening. Prostate cancer screening. http://www.cancerscreening.gov.au/internet/screening/publishing.nsf/Content/prostate-cancer-screening? (viewed Apr 2018).
                    • 15. Olver I, Brooks DA, Esterman A. Cancer biomarkers in Australia. Adelaide: University of South Australia, 2017. http://www.unisa.edu.au/Global/Health/Research/Cancer%20Biomarkers%20in%20Australia%20Report.pdf (viewed Mar 2018).
                    • 16. Pal RP, Kockelbergh RC, Pringle JH, et al. Immunocytochemical detection of ERG expression in exfoliated urinary cells identifies with high specificity patients with prostate cancer. BJU Int 2016; 117: 686-696.
                    • 17. Eklund M, Nordström T, Aly M, et al. The Stockholm-3 (STHLM3) model can improve prostate cancer diagnostics in men aged 50-69 yr compared with current prostate cancer testing. Eur Urol Focus 2016; doi:10.1016/j.eurf.2016.10.009 [Epub ahead of print].
                    • 18. Hille C, Pantel K. Prostate cancer: circulating tumour cells in prostate cancer. Nat Rev Urol 2018; doi:10.1038/nrurol.2018.25 [Epub ahead of print].
                    • 19. Johnson IRD, Parkinson-Lawrence EJ, Keegan H, et al. Endosomal gene expression: an important new indicator for prostate cancer patient prognosis? Oncotarget 2015; 6: 37919-37929.
                    Online responses are no longer available. Please refer to our instructions for authors page for more information.

                      Active surveillance of men with low risk prostate cancer: evidence from the Prostate Cancer Outcomes Registry–Victoria

                      Melanie A Evans, Jeremy L Millar, Arul Earnest, Mark Frydenberg, Ian D Davis, Declan G Murphy, Paul Aidan Kearns and Sue M Evans
                      Med J Aust 2018; 208 (10): . || doi: 10.5694/mja17.00559
                      Published online: 28 May 2018

                      Abstract

                      Objective: To characterise the practice of active surveillance (AS) for men with low risk prostate cancer by examining the characteristics of those who commence AS, the rate of adherence to accepted AS follow-up protocols over 2 years, and factors associated with good adherence.

                      Design, setting: Retrospective cohort study; analysis of data collected from 38 sites participating in the Prostate Cancer Outcomes Registry–Victoria.

                      Participants: Men diagnosed with prostate cancer between August 2008 and December 2014 aged 75 years or less at diagnosis, managed by AS for at least 2 years, and with an ISUP grade group of 3 or less (Gleason score no worse than 4 + 3 = 7).

                      Main outcome measures: Adherence to an AS schedule consisting of at least three PSA measurements and at least one biopsy in the 2 years following diagnosis.

                      Results: Of 1635 men eligible for inclusion in the analysis, 433 (26.5%) adhered to the AS protocol. The significant predictor of adherence in the multivariate model was being diagnosed in a private hospital (v public hospital: adjusted odds ratio [aOR], 1.83; 95% CI, 1.42–2.37; P < 0.001). Significant predictors of non-adherence included being diagnosed by transurethral resection of the prostate (v transrectal ultrasound biopsy [TRUS]: OR, 0.54; 95% CI, 0.39–0.77; P < 0.001) or transperineal biopsy (v TRUS: OR, 0.32; 95% CI, 0.19–0.52; P < 0.001), and being 66 years of age or more at diagnosis (v < 55 years: OR, 0.65; 95% CI, 0.45–0.92; P = 0.015).

                      Conclusion: Almost three-quarters of men who had prostate cancer with low risk of disease progression did not have follow-up investigations consistent with standard AS protocols. The clinical consequences of this shortcoming are unknown.

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                      • 1 Monash University, Melbourne, VIC
                      • 2 Alfred Health, Melbourne, VIC
                      • 3 Monash Health, Melbourne, VIC
                      • 4 Eastern Health Clinical School, Monash University, Melbourne, VIC
                      • 5 The Peter MacCallum Cancer Centre, Melbourne, VIC
                      • 6 University of Melbourne, Melbourne, VIC
                      • 7 Barwon Health, Geelong, VIC
                      • 8 Geelong Urology, Geelong, VIC


                      Correspondence: sue.evans@monash.edu
                      Acknowledgements: 

                      Funding for this project has been provided by the Movember Foundation. Ian Davis is supported by a National Health and Medical Research Council Practitioner Fellowship (APP1102604). Sue Evans is supported by a Monash Partners Academic Health Science Centre Fellowship.

                      Competing interests:

                      No relevant disclosures.

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