Topics

Abstract

Objectives: To examine the clinical characteristics and short term outcomes for children with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) infections who presented to Australian hospitals during 2020 and 2021.

Design, setting: Retrospective case review study in nineteen hospitals of the Paediatric Research in Emergency Departments International Collaborative (PREDICT) network from all Australian states and territories, including seven major paediatric tertiary centres and eight Victorian hospitals.

Participants: SARS‐CoV‐2‐positive people under 18 years of age who attended emergency departments or were admitted to hospital during 1 February 2020 – 31 December 2021.

Main outcome measures: Epidemiological and clinical characteristics, by hospital care type (emergency department [ED] or inpatient care).

Results: A total of 1193 SARS‐CoV‐2‐positive children and adolescents (527 girls, 44%) attended the participating hospitals (107 in 2020, 1086 in 2021). Their median age was 3.8 years (interquartile range [IQR], 0.8–11.4 years); 63 were Aboriginal or Torres Strait Islander people (5%). Other medical conditions were recorded for 293 children (25%), including asthma (86, 7%) and premature birth (68, 6%). Medical interventions were not required during 795 of 1181 ED presentations (67%); children were discharged directly home in 764 cases (65%) and admitted to hospital in 282 (24%; sixteen to intensive care units). The 384 admissions to hospital (including 102 direct admissions) of 341 children (25 infants under one month of age) included 23 to intensive care (6%); the median length of stay was three days (IQR, 1–9 days). Medical interventions were not required during 261 admissions (68%); 44 children received respiratory support (11%) and 21 COVID‐19‐specific treatments, including antiviral and biologic agents (5%). Being under three months of age (v one year to less than six years: odds ratio [OR], 2.6; 95% confidence interval [CI], 1.7–4.0) and pre‐existing medical conditions (OR, 2.5; 95% CI, 1.9–3.2) were the major predictors of hospital admission. Two children died, including one without a known pre‐existing medical condition.

Conclusion: During 2020 and 2021, most SARS‐CoV‐2‐positive children and adolescents who presented to participating hospitals could be managed as outpatients. Outcomes were generally good, including for those admitted to hospital.

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1 Royal Children's Hospital, Melbourne, Melbourne, VIC
2 Murdoch Children's Research Institute, Melbourne, VIC
3 PREDICT Research Network, Melbourne, VIC
4 Western Health, Melbourne, VIC
5 Northern Hospital Epping, Melbourne, VIC
6 The Children's Hospital at Westmead, Sydney, NSW
7 The Children's Hospital at Westmead Clinical School, the University of Sydney, Sydney, NSW
8 John Hunter Hospital, Newcastle, NSW
9 Women's and Children's Hospital, Adelaide, SA
10 Auburn Hospital, Sydney, NSW
11 University of Notre Dame, Sydney, NSW
12 Gold Coast University Hospital, Gold Coast, QLD
13 Child Health Research Centre, the University of Queensland, Brisbane, QLD
14 Queensland Children's Hospital, Brisbane, QLD
15 Eastern Health, Melbourne, VIC
16 Eastern Health Clinical School, Monash University, Melbourne, VIC
17 University Hospital Geelong, Geelong, VIC
18 Austin Hospital, Melbourne, VIC
19 Canberra Hospital, Canberra, ACT
20 Royal Darwin and Palmerston Hospital, Darwin, NT
21 Sunshine Coast University Hospital, Sunshine Coast, QLD
22 Perth Children's Hospital, Perth, WA
23 Curtin University, Perth, WA
24 Royal Hobart Hospital, Hobart, TAS
25 Tasmanian School of Medicine, University of Tasmania, Hobart, TAS
26 The University of Melbourne, Melbourne, VIC

Correspondence: laila.ibrahim@mcri.edu.au

Open access:

Open access publishing facilitated by The University of Melbourne, as part of the Wiley – The University of Melbourne agreement via the Council of Australian University Librarians.

Acknowledgements:

We acknowledge the support of the National Health and Medical Research Council (NHMRC) through a Centre of Research Excellence grant for Paediatric Emergency Medicine (1171228), which also supported Catherine Wilson, who coordinated the study and data collection across the PREDICT network. Franz Babl is supported by an NHMRC Practitioner Fellowship (1124468), which partially supported his role as a senior author and principal investigator for this study.

We also acknowledge the assistance of the hospital staff who assisted with data retrieval: Katrina Pandey and James Gaston (Sunshine Hospital, Western Health); Deepali Thosar (the Children's Hospital at Westmead); Giles Barrington (Royal Hobart Health Service); Amelia Skaczkowski (Royal Darwin Hospital); Jo Miller, Ethan Fernandes, Andrew McGlinchy, Ye Yang Tham, and Olivia Slifirski (Eastern Health: Box Hill, Maroondah, and Angliss hospitals); Gaby Nieva and Lara Caruso (Adelaide Women's and Children's Hospital); Angus Jones and Alyce Callaghan (Queensland Children's Hospital); and Nitaa Eapen, Yilin Liu, Karen Lu, Violet Sattari Bahri, Michael Wojno, Haoyue Zhang, and Zahra Ataie‐Ashtiani (Royal Children's Hospital).

Competing interests:

No relevant disclosures.

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Editorials

Long COVID in Australia: achieving equitable access to supportive health care

Tania C Sorrell, Martin Hensher and Lena A Sanci

Med J Aust 2023; 218 (10): . || doi: 10.5694/mja2.51950
Published online: 5 June 2023

ARTICLE
AUTHORS
REFERENCES

Topics

Infectious diseases

Health services administration

General medicine

Our stressed health system needs innovative solutions to care adequately for people with post‐COVID‐19 conditions

The post-coronavirus disease 2019 (COVID-19) condition or syndrome (“long COVID”) is defined as the persistence of existing symptoms or the development of new symptoms, without an alternative explanation, three months after an initial acute severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection. The symptoms, of varying and inconstant severity, can impair everyday functioning. Although long COVID can affect many body systems, the most frequent symptoms are fatigue, shortness of breath, and cognitive dysfunction.1 Long COVID lasting more than twelve weeks is estimated to affect 5–10% of people in Australia who have had COVID-19,2 but lower rates following SARS-CoV-2 infections since 2022 have recently been reported in the United Kingdom (4.0% of first infections in adults, 2.4% of re-infections).3

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1 Sydney Institute for Infectious Diseases, the University of Sydney, Sydney, NSW
2 Menzies Institute for Medical Research, University of Tasmania College of Health and Medicine, Hobart, TAS
3 Melbourne Medical School, the University of Melbourne, Melbourne, VIC

Correspondence: tania.sorrell@sydney.edu.au

Acknowledgements:

We acknowledge the work of the fellows of the Australian Academy of Health and Medical Sciences and the Australian Academy of Science and of other experts who contributed to a joint written submission to the Parliamentary Inquiry into Long COVID and Repeated COVID Infections and a subsequent roundtable discussion with the Standing Committee on Health, Aged Care and Sport. The final report of the Standing Committee was released on 24 April 2023.13 The Minister for Health and Aged Care, the Hon. Mark Butler MP, subsequently announced that $50 million would be provided from the Medical Research Future Fund for long COVID research.14

Competing interests:

Martin Hensher was a member of the National COVID‐19 Health and Research Advisory Committee Working Group on Long COVID (unremunerated). Lena Sanci co‐leads the long COVID project in APPRISE (Australian Partnership for Preparedness Research on Infectious Disease Emergencies, a Centre for Research Excellence. Tania Sorrell is a chief investigator and an executive member of APPRISE, but has received no remuneration in relation to the Long COVID project.

1. World Health Organization. A clinical case definition of post COVID‐19 condition by a Delphi consensus. Geneva: WHO, 2021. https://www.who.int/publications/i/item/WHO‐2019‐nCoV‐Post_COVID‐19_condition‐Clinical_case_definition‐2021.1 (viewed April 2023).
2. Australian Institute of Health and Welfare. Long COVID in Australia: a review of the literature (AIHW cat. no. PHE 318). 16 Dec 2022. https://www.aihw.gov.au/reports/covid‐19/long‐covid‐in‐australia‐a‐review‐of‐the‐literature/summary (viewed Apr 2023).
3. Office for National Statistics (UK). New‐onset, self‐reported long COVID after coronavirus (COVID‐19) reinfection in the UK. 23 Feb 2023. https://www.ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/conditionsanddiseases/bulletins/newonsetselfreportedlongcovidaftercoronaviruscovid19reinfectionintheuk/23february2023 (viewed Apr 2023).
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10. Royal Australian College of General Practitioners. Caring for patients with post‐COVID‐19 conditions. Melbourne: RACGP, 2022. https://www.racgp.org.au/clinical‐resources/covid‐19‐resources/clinical‐care/caring‐for‐patients‐with‐post‐covid‐19‐conditions/introduction (viewed Apr 2023).
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Perspectives

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Upholding our rights in research: calling for urgent investment in Aboriginal and Torres Strait Islander health research ethics

Michelle Kennedy and Janine Mohamed

Med J Aust || doi: 10.5694/mja2.51951
Published online: 5 June 2023

ARTICLE
AUTHORS
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Topics

Indigenous health

Ethics and law

Environment and public health

Growth in Aboriginal and Torres Strait Islander health research requires urgent investment in Aboriginal and Torres Strait Islander ethical governance

Indigenous peoples have been conducting research to understand complex systems of knowledge since time immemorial.1 The embodiment of principles aligned with Indigenous ways of knowing, being and doing is central to the legacy of this expert research practice. In this perspective article, we draw on our lived experiences and a review on the field of practice of ethical research.

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1 University of Newcastle, Newcastle, NSW
2 Lowitja Institute, Melbourne, VIC

Correspondence: michelle.kennedy11@newcastle.edu.au

Open access

Open access publishing facilitated by The University of Newcastle, as part of the Wiley ‐ The University of Newcastle agreement via the Council of Australian University Librarians.

Competing interests:

No relevant disclosures.

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14. Australian Government, Department of Health and Aged Care. National Aboriginal and Torres Strait Islander Health Workforce Strategic Framework and Implementation Plan 2021–2031. Canberra: Commonwealth of Australia, 2021. https://www.health.gov.au/sites/default/files/documents/2022/03/national‐aboriginal‐and‐torres‐strait‐islander‐health‐workforce‐strategic‐framework‐and‐implementation‐plan‐2021‐2031.pdf (viewed Jan 2023).
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Commercial determinants of human rights: for‐profit health care and housing

Jennifer Lacy‐Nichols, Rebecca Bentley and Adam G Elshaug

Med J Aust || doi: 10.5694/mja2.51982
Published online: 5 June 2023

ARTICLE
AUTHORS
REFERENCES

Topics

Health services administration

Social determinants of health

What do the commercial determinants of health look like for goods and services that are human rights?

Follow the money. This is the premise driving commercial determinants of health (CDoH) research. Why do children see gambling advertisements when they watch professional sports? Why do vapes have cartoon logos and candy flavours? Why don't we have better implementation of the Framework Convention on Tobacco Control? Why has progress stagnated on the Paris Climate deal? Money, profits and power cut through all these issues.

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1 Centre for Health Policy, University of Melbourne, Melbourne, VIC
2 Menzies Centre for Health Policy and Economics, University of Sydney, Sydney, NSW

Correspondence: jennifer.lacy@unimelb.edu.au

Open access

Open access publishing facilitated by The University of Melbourne, as part of the Wiley ‐ The University of Melbourne agreement via the Council of Australian University Librarians.

Competing interests:

Jennifer Lacy‐Nichols is the recipient of a Fellowship from the Victorian Health Promotion Foundation. Adam Elshaug is Ministerially appointed to the Strengthening Medicare Taskforce and the Medicare Benefits Schedule Review Advisory Committee (MRAC); is health economic and policy advisor to Cancer Australia; is a member of the Research Partnership Advisory Group (translational research priorities 2022–24), Victorian Government Department of Health; is a member of the Victorian Perioperative Learning Health Network Advisory Group (Safer Care Victoria);and holds grants from the National Health and Medical Research Council and the Medical Research Future Fund.

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3. Hyder AA, Werbick M, Scannelli L, Paichadze N. The COVID‐19 pandemic exposes another commercial determinant of health: the global firearm industry. Glob Health Sci Pract 2021; 9: 264‐267.
4. Klein DE, Lima JM. The prison industrial complex as a commercial determinant of health. Am J Public Health 2021; 111: 1750‐1752.
5. Zenone M, Kenworthy N, Maani N. The social media industry as a commercial determinant of health. Int J Health Policy Manag 2022; 12: 6840.
6. Freudenberg N. Lethal but legal: corporations, consumption, and protecting public health. New York: Oxford University Press, 2014.
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9. Lee K, Freudenberg N, Zenone M, et al. Measuring the commercial determinants of health and disease: a proposed framework. Int J Health Serv 2022; 52: 115‐128.
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20. Erny‐Albrecht K, Bywood P. Corporatisation of general practice — impact and implications. PHCRIS policy issue review. Adelaide: Primary Health Care Research and Information Service, 2016.
21. Bambra C, Gibson M, Sowden A, et al. Tackling the wider social determinants of health and health inequalities: evidence from systematic reviews. J Epidemiol Community Health 2010; 64: 284‐291.
22. Urban Reform Institute, Frontier Centre for Public Policy. International housing affordability. Demographia, 2023. http://www.demographia.com/dhi.pdf (viewed Apr 2023).
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24. Pawson H, Lilley D. Managing access to social housing in Australia: unpacking policy frameworks and service provision outcomes. Sydney: UNSW City Futures Research Centre, 2022.
25. Mishra SR, Wilson T, Andrabi H, et al. The total health gains and cost savings of eradicating cold housing in Australia. Soc Sci Med 2023; doi:https://doi.org/10.1016/j.socscimed.2023.115954.
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Research letters

The impact on poisonings of up‐scheduling of modified release paracetamol to Schedule 3 (pharmacist only medicine)

Rose Cairns, Firouzeh Noghrehchi and Nicholas A Buckley

Med J Aust 2023; 218 (9): . || doi: 10.5694/mja2.51888
Published online: 15 May 2023

ARTICLE
AUTHORS
REFERENCES

Topics

Poisoning

Pharmaceutical preparations

Health services administration

Mental disorders

In Australia, paracetamol is the agent most frequently implicated in drug overdoses, and their frequency is increasing, particularly in young people.1 Paracetamol overdose causes significant morbidity despite treatment, and is the leading cause of acute liver failure in Western countries.2 Modified release (MR) paracetamol overdose is associated with a higher rate of liver injury than immediate release paracetamol.3 The sole therapeutic benefit of MR paracetamol is its more convenient dosage regimen (three rather than four times a day).4

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1 The University of Sydney, Sydney, NSW
2 NSW Poisons Information Centre, Children's Hospital at Westmead, Sydney, NSW

Correspondence: rose.cairns@health.nsw.gov.au

Open access

Open access publishing facilitated by The University of Sydney, as part of the Wiley – The University of Sydney agreement via the Council of Australian University Librarians.

Acknowledgements:

Rose Cairns is supported by a National Health and Medical Research Council (NHMRC) Investigator Grant (1196516); Nicholas Buckley is supported by an NHMRC investigator Grant (2007726). We thank the staff of the New South Wales Poisons Information Centre for collecting the data analysed in our study.

Competing interests:

Rose Cairns holds an untied educational grant from Reckitt; this funder had no role in this study.

1. Buckley N, Calear A, Cairns R, et al; Therapeutic Goods Administration. Independent expert report on the risks of intentional self‐poisoning with paracetamol. Aug 2022. https://www.tga.gov.au/sites/default/files/2022‐09/paracetamol_report_final.pdf (viewed Feb 2023).
2. Ostapowicz G, Fontana RJ, Schiødt FV, et al; U.S. Acute Liver Failure Study Group. Results of a prospective study of acute liver failure at 17 tertiary care centres in the United States. Ann Intern Med 2002; 137: 947‐954.
3. Chiew AL, Reith D, Pomerleau A, et al. Updated guidelines for the management of paracetamol poisoning in Australia and New Zealand. Med J Aust 2020; 212: 175‐183. https://www.mja.com.au/journal/2020/212/4/updated‐guidelines‐management‐paracetamol‐poisoning‐australia‐and‐new‐zealand
4. Bacon TH, Hole JG, North M, Burnett I. Analgesic efficacy of sustained release paracetamol in patients with osteoarthritis of the knee. Br J Clin Pharmacol 2002; 53: 629‐636.
5. Therapeutic Goods Administration. Final decision in relation to paracetamol (modified release). 26 Aug 2019. https://www.tga.gov.au/resources/publication/scheduling‐decisions‐final/notice‐final‐decision‐amend‐or‐not‐amend‐current‐poisons‐standard‐august‐2019/14‐final‐decision‐relation‐paracetamol‐modified‐release (viewed Mar 2023).
6. European Medicines Agency. Paracetamol modified‐release. 1 Mar 2018. https://www.ema.europa.eu/en/medicines/human/referrals/paracetamol‐modified‐release (viewed Mar 2023).
7. Royal Australian College of General Practitioners. Submission to the Therapeutic Goods Administration: public consultation on proposed amendments to the Poisons Standard (paracetamol). 17 Oct 2022. https://www.racgp.org.au/advocacy/reports‐and‐submissions/view‐all‐reports‐and‐submissions/2022‐reports‐and‐submissions/submission‐to‐the‐therapeutic‐goods‐administra‐1 (viewed Mar 2023).
8. Cairns R, Schaffer AL, Brown JA, et al. Codeine use and harms in Australia: evaluating the effects of re‐scheduling. Addiction 2020; 115: 451‐445.
9. Therapeutic Goods Administration. Notice of interim decisions to amend (or not amend) the current Poisons Standard. 3 Feb 2023. https://www.tga.gov.au/sites/default/files/2023‐02/public‐notice‐of‐interim‐decisions‐acms‐40‐accs‐35‐joint‐acms‐accs‐32‐november‐2022.pdf (viewed Feb 2023).

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Research letters

Comparison of performance outcomes after general practice training in remote and rural or regional locations in Australia

Emily Anderson, Matthew R McGrail, Aaron Hollins, Louise Young, Lawrie McArthur, Belinda O'Sullivan and Tiana Gurney

Med J Aust 2023; 218 (9): . || doi: 10.5694/mja2.51930
Published online: 15 May 2023

ARTICLE
AUTHORS
REFERENCES

Topics

General medicine

Medical education

General practice training is provided in geographically diverse locations across Australia to promote the development of the rural and remote medical workforce. Training in rural and remote locations supports learning locally required types of medical practice and builds both social and professional connections that increase the likelihood of trainees later practising in these communities.1,2 The remote learning model appears to be successful,3 but a 2020 scoping review found only limited evidence for the equivalence of learning outcomes after training in remote or less remote locations.4 We therefore compared formative assessment outcomes for general practice trainees in remote locations with those of trainees in rural or regional locations.

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1 James Cook University, Townsville, QLD
2 Rural Clinical School, University of Queensland, Rockhampton, QLD
3 Rural Clinical School, University of Queensland, Toowoomba, QLD

Correspondence: emma.anderson1@jcu.edu.au

Open access

Open access publishing facilitated by James Cook University, as part of the Wiley – James Cook University agreement via the Council of Australian University Librarians.

Acknowledgements:

This project was funded by an Education Research Grant from the Australian College of Rural and Remote Medicine (salaries and research costs).

Competing interests:

No relevant disclosures.

1. Kanakis K, Young L, Reeve C, et al. How does GP training impact rural and remote underserved communities? Exploring community and professional perceptions. BMC Health Serv Res 2020; 20: 812.
2. McGrail MR, Russell DJ, Campbell DG. Vocational training of general practitioners in rural locations is critical for the Australian rural medical workforce. Med J Aust 2016; 205: 216‐221. https://www.mja.com.au/journal/2016/205/5/vocational‐training‐general‐practitioners‐rural‐locations‐critical‐australian
3. Giddings P, McLaren J. Rural medical training via distance education and remote supervision. In: Chater AB, Rourke J, Couper ID, et al (eds). WONCA rural medical education guidebook. World Organization of Family Doctors, Apr 2014. https://www.globalfamilydoctor.com/site/DefaultSite/filesystem/documents/ruralGuidebook/RMEG.pdf (viewed Apr 2023).
4. Reeve C, Johnston K, Young L. Health profession education in remote or geographically isolated settings: a scoping review. J Med Educ Curric Dev 2020; 7: 2382120520943595.
5. Australian Department of Health and Aged Care. Modified Monash Model. Updated 14 Dec 2021. https://www.health.gov.au/topics/rural‐health‐workforce/classifications/mmm (viewed Mar 2023).
6. Young L, Peel R, O'Sullivan B, Reeve C. Building general practice training capacity in rural and remote Australia with underserved primary care services: a qualitative investigation. BMC Health Serv Res 2019; 19: 338.
7. Couch D, O'Sullivan B, Russell D, McGrail M. “It's so rich, you know, what they could be experiencing”: rural places for general practitioner learning. Health Sociol Rev 2020; 29: 76‐91.
8. Australian Department of Health and Aged Care. National medical workforce strategy 2021–2031. Updated 20 Jan 2022. https://www.health.gov.au/our‐work/national‐medical‐workforce‐strategy‐2021‐2031 (viewed Mar 2023).

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Research

The diagnosis and initial management of melanoma in Australia: findings from the prospective, population‐based QSkin study

Nirmala Pandeya, Catherine M Olsen, Maja M Shalit, Jean Claude Dusingize, Rachel E Neale and David C Whiteman

Med J Aust 2023; 218 (9): . || doi: 10.5694/mja2.51919
Published online: 15 May 2023

ARTICLE
AUTHORS
REFERENCES

Topics

Neoplasms

General medicine

Statistics, epidemiology and research design

Abstract

Objectives: To determine the proportions of newly diagnosed melanomas treated by different medical specialist types, to describe the types of excisions performed, and to investigate factors associated with treating practitioner specialty and excision type.

Design, setting: Prospective cohort study; analysis of linked data: baseline surveys, hospital, pathology, Queensland Cancer Register, and Medical Benefits Schedule databases.

Participants: Random sample of 43 764 Queensland residents aged 40–69 years recruited during 2011, with initial diagnoses of in situ or invasive melanoma diagnosed to 31 December 2019.

Main outcome measures: Treating practitioner type and treatment modality for first incident melanoma; second and subsequent treatment events for the primary melanoma.

Results: During a median follow‐up of 8.4 years (interquartile range, 8.3–8.8 years), 1683 eligible participants (720 women, 963 men) developed at least one primary melanoma (in situ melanoma, 1125; invasive melanoma, 558), 1296 of which (77.1%) were initially managed in primary care; 248 were diagnosed by dermatologists (14.8%), 83 by plastic surgeons (4.9%), 43 by general surgeons (2.6%), and ten by other specialists (0.6%). The most frequent initial procedures leading to histologically confirmed melanoma diagnosis were first excision (854, 50.7%), shave biopsy (549, 32.6%), and punch biopsy (178, 10.6%); 1339 melanomas (79.6%) required two procedures, 187 (11.1%) three. Larger proportions of melanomas diagnosed by dermatologists (87%) or plastic surgeons (71%) were in people living in urban areas than of those diagnosed in primary care (63%); larger proportions of melanomas diagnosed by dermatologists or plastic surgeons than of those diagnosed in primary care were in people with university degrees (45%, 42% v 23%) or upper quartile clinical risk scores (63%, 59% v 47%).

Conclusions: Most incident melanomas in Queensland are diagnosed in primary care, and nearly half are initially managed by partial excision (shave or punch biopsy). Second or third, wider excisions are undertaken in about 90% of cases.

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QIMR Berghofer Medical Research Institute, Brisbane, QLD

Correspondence: david.whiteman@qimrberghofer.edu.au

Open access

Open access publishing facilitated by The University of Queensland, as part of the Wiley – The University of Queensland agreement via the Council of Australian University Librarians.

Acknowledgements:

This study was supported by the National Health and Medical Research Council (NHMRC; APP1073898; APP1063061; APP1185416). David Whiteman is supported by an NHMRC Research Fellowship (APP11554130). The funders played no role in the design, execution, analysis or interpretation of this study. We thank Cancer Alliance Queensland who maintain the Queensland Cancer Register for their valuable contributions to this study.

Competing interests:

No relevant disclosures.

1. Olsen CM, Green AC, Pandeya N, Whiteman DC. Trends in melanoma incidence rates in eight susceptible populations to 2015. J Invest Dermatol 2019; 139: 1392‐1395.
2. Gordon LG, Leung W, Johns R, et al. Estimated healthcare costs of melanoma and keratinocyte skin cancers in Australia and Aotearoa New Zealand in 2021. Int J Res Public Health 2022; 19: 3178.
3. Australian Institute of Health and Welfare. Risk of melanoma of the skin by age and over time. In: Cancer data in Australia. Updated 4 Oct 2020. https://www.aihw.gov.au/reports/cancer/cancer‐data‐in‐australia/contents/cancer‐data‐commentaries/risk‐of‐melanoma‐of‐the‐skin‐by‐age‐and‐over‐time (viewed Dec 2022).
4. Thompson BS, Pandeya N, Olsen CM, et al. Keratinocyte cancer excisions in Australia: who performs them and associated costs. Australas J Dermatol 2019; 60: 294‐300.
5. Hollestein L, Weinstock M, Le Roux E, Olsen C. More than many: how to manage the most frequent cancer? J Invest Dermatol 2017; 137: 1823‐1826.
6. Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice (Red Book). 9th edition. Melbourne: RACGP, 2022. https://www.racgp.org.au/download/Documents/Guidelines/Redbook9/17048‐Red‐Book‐9th‐Edition.pdf (viewed Dec 2022).
7. Cancer Council Victoria; Victorian Department of Health. Optimal care pathway for people with melanoma. 2nd edition. June 2021. https://www.cancer.org.au/assets/pdf/melanoma‐optimal‐cancer‐care‐pathway (viewed Dec 2022).
8. Cancer Council Australia Melanoma Guidelines Working Party. Clinical practice guidelines for the diagnosis and management of melanoma. 2018. https://wiki.cancer.org.au/australia/Guidelines:Melanoma (viewed July 2022).
9. Wu A, Rosen R, Selva D, Huilgol SC. Proportion of melanoma excisions performed by different specialties in Australia. Australas J Dermatol 2018; 59: 243‐245.
10. de Menezes SL, Wolfe R, Kelly JW, et al. Think before you shave: factors influencing choice of biopsy technique for invasive melanoma and effect on definitive management. Australas J Dermatol 2020; 61: 134‐139.
11. Smithers BM, Hughes MCB, Beesley VL, et al. Prospective study of patterns of surgical management in adults with primary cutaneous melanoma at high risk of spread, in Queensland, Australia. J Surg Oncol 2015; 112: 359‐365.
12. Kelly JW, Henderson MA, Thursfield VJ, et al. The management of primary cutaneous melanoma in Victoria in 1996 and 2000. Med J Aust 2007; 187: 511‐514. https://www.mja.com.au/journal/2007/187/9/management‐primary‐cutaneous‐melanoma‐victoria‐1996‐and‐2000
13. Baade P, Meng X, Youlden D, et al. Time trends and latitudinal differences in melanoma thickness distribution in Australia, 1990–2006. Int J Cancer 2012; 130: 170‐178.
14. Olsen CM, Green AC, Neale RE, et al; QSkin Study. Cohort profile: the QSkin Sun and Health Study. Int J Epidemiol 2012; 41: 929‐i.
15. Morze CJ, Olsen CM, Perry SL, et al; QSkin Study. Good test–retest reproducibility for an instrument to capture self‐reported melanoma risk factors. J Clin Epidemiol 2012; 65: 1329‐1336.
16. Mortimore A, Pandeya N, Olsen CM, Whiteman DC. “Repeatability of repeatability”: the stability of self‐reported melanoma risk factors in two independent samples. Aust N Z J Public Health 2021; 45: 469‐473.
17. Olsen CM, Pandeya N, Thompson BS, et al; QSkin Study. Risk stratification for melanoma: models derived and validated in a purpose‐designed prospective cohort. J Natl Cancer Inst 2018; 110: 1075‐1083.
18. Blizzard L, Hosmer DW. The log multinomial regression model for nominal outcomes with more than two attributes. Biom J 2007; 49: 889‐902.
19. Medical Board of Australia. Medical board of Australia registrant data. 2022. Reporting period: 01 October 2022 to 31 December 2022. https://www.ahpra.gov.au/documents/default.aspx?record=WD23%2f32565&dbid=AP&chksum=q0%2fqnb5I7i7w6DCShektSQ%3d%3d (viewed Feb 2023).
20. Hay J, Keir J, Jimenez Balcells C, et al. Characteristics, treatment and outcomes of 589 melanoma patients documented by 27 general practitioners on the Skin Cancer Audit Research Database. Australas J Dermatol 2022; 63: 204‐212.
21. Doolan BJ, Robinson AJ, Wolfe R, et al. Accuracy of partial biopsies in the management of cutaneous melanoma. Australas J Dermatol 2019; 60: 209‐213.
22. Wilkinson D, Askew DA, Dixon A. Skin cancer clinics in Australia: workload profile and performance indicators from an analysis of billing data. Med J Aust 2006; 184: 162‐164. https://www.mja.com.au/journal/2006/184/4/skin‐cancer‐clinics‐australia‐workload‐profile‐and‐performance‐indicators
23. Wilkinson D, Kitcheber S, Bourne P, Dixon A. Skin cancer medicine in primary care: towards an agenda for quality health outcomes. Med J Aust 2006; 184: 11‐12. https://www.mja.com.au/journal/2006/184/1/skin‐cancer‐medicine‐primary‐care‐towards‐agenda‐quality‐health‐outcomes
24. Olsen CM, Wilson LF, Green AC, et al. Cancers in Australia attributable to exposure to solar ultraviolet radiation and prevented by regular sunscreen use. Aust N Z J Public Health 2015; 39: 471‐476.

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Research

Universal genetic testing for women with newly diagnosed breast cancer in the context of multidisciplinary team care

Dilanka L De Silva, Lesley Stafford, Anita R Skandarajah, Michelle Sinclair, Lisa Devereux, Kirsten Hogg, Maira Kentwell, Allan Park, Luxi Lal, Magnus Zethoven, Madawa W Jayawardana, Fiona Chan, Phyllis N Butow, Paul A James, G Bruce Mann, Ian G Campbell and Geoffrey J Lindeman

Med J Aust 2023; 218 (8): . || doi: 10.5694/mja2.51906
Published online: 1 May 2023

ARTICLE
AUTHORS
REFERENCES

Topics

Neoplasms

Medical genetics

Diagnostic techniques and procedures

Abstract

Objective: To determine the feasibility of universal genetic testing of women with newly diagnosed breast cancer, to estimate the incidence of pathogenic gene variants and their impact on patient management, and to evaluate patient and clinician acceptance of universal testing.

Design, setting, participants: Prospective study of women with invasive or high grade in situ breast cancer and unknown germline status discussed at the Parkville Breast Service (Melbourne) multidisciplinary team meeting. Women were recruited to the pilot (12 June 2020 – 22 March 2021) and expansion phases (17 October 2021 – 8 November 2022) of the Mutational Assessment of newly diagnosed breast cancer using Germline and tumour genomICs (MAGIC) study.

Main outcome measures: Germline testing by DNA sequencing, filtered for nineteen hereditary breast and ovarian cancer genes that could be classified as actionable; only pathogenic variants were reported. Surveys before and after genetic testing assessed pilot phase participants’ perceptions of genetic testing, and psychological distress and cancer‐specific worry. A separate survey assessed clinicians’ views on universal testing.

Results: Pathogenic germline variants were identified in 31 of 474 expanded study phase participants (6.5%), including 28 of 429 women with invasive breast cancer (6.5%). Eighteen of the 31 did not meet current genetic testing eligibility guidelines (probability of a germline pathogenic variant ≥ 10%, based on CanRisk, or Manchester score ≥ 15). Clinical management was changed for 24 of 31 women after identification of a pathogenic variant. Including 68 further women who underwent genetic testing outside the study, 44 of 542 women carried pathogenic variants (8.1%). Acceptance of universal testing was high among both patients (90 of 103, 87%) and clinicians; no decision regret or adverse impact on psychological distress or cancer‐specific worry were reported.

Conclusion: Universal genetic testing following the diagnosis of breast cancer detects clinically significant germline pathogenic variants that might otherwise be missed because of testing guidelines. Routine testing and reporting of pathogenic variants is feasible and acceptable for both patients and clinicians.

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1 The University of Melbourne, Melbourne, VIC
2 Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, VIC
3 Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
4 The Royal Melbourne Hospital, Melbourne, VIC
5 Royal Women's Hospital, Melbourne, VIC
6 Peter MacCallum Cancer Centre, Melbourne, VIC
7 Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC
8 The Royal Children's Hospital Melbourne, Melbourne, VIC
9 Centre for Medical Psychology and Evidence‐based Decision Making, the University of Sydney, Sydney, NSW

Correspondence: gjl@unimelb.edu.au

Open access

Open access publishing facilitated by The University of Melbourne, as part of the Wiley ‐ The University of Melbourne agreement via the Council of Australian University Librarians.

Acknowledgements:

We thank the women who took part in the study, as well as the staff of the Parkville Breast Service and the Parkville Familial Cancer Centre for their assistance and support. The study was supported by grants from the National Breast Cancer Foundation (IIRS‐20‐080) and the National Health and Medical Research Council (NHMRC; 1153049). Geoffrey J Lindeman is supported by an NHMRC Leadership Fellowship (1175960) and the Breast Cancer Research Foundation.

Competing interests:

No relevant disclosures.

1. De Silva DL, James PA, Mann GB, Lindeman GJ. Universal genetic testing of patients with newly diagnosed breast cancer: ready for prime time? Med J Aust 2021; 215: 449‐453. https://www.mja.com.au/journal/2021/215/10/universal‐genetic‐testing‐patients‐newly‐diagnosed‐breast‐cancer‐ready‐prime
2. Richards S, Aziz N, Bale S, et al; ACMG Laboratory Quality Assurance Committee. Standards and guidelines for the interpretation of sequence variants: a joint consensus recommendation of the American College of Medical Genetics and Genomics and the Association for Molecular Pathology. Genet Med 2015; 17: 405‐424.
3. Cancer Institute NSW. BRCA1 and BRCA2: genetic testing (EviQ 620 v.12). Reviewed 2 July 2020. https://www.eviq.org.au/cancer‐genetics/adult/genetic‐testing‐for‐heritable‐pathogenic‐variants/620‐brca1‐and‐brca2‐genetic‐testing (viewed Feb 2023).
4. Carver T, Hartley S, Lee A, et al. CanRisk tool: a web interface for the prediction of breast and ovarian cancer risk and the likelihood of carrying genetic pathogenic variants. Cancer Epidemiol Biomarkers Prev 2021; 30: 469‐473.
5. Antoniou AC, Hardy R, Walker L, et al. Predicting the likelihood of carrying a BRCA1 or BRCA2 mutation: validation of BOADICEA, BRCAPRO, IBIS, Myriad and the Manchester scoring system using data from UK genetics clinics. J Med Genet 2008; 45: 425‐431.
6. Kirk J, Barlow‐Stewart KK, Poplawski NK, et al. Medicare‐funded cancer genetic tests: a note of caution. Med J Aust 2018; 209: 193‐196. https://www.mja.com.au/journal/2018/209/5/medicare‐funded‐cancer‐genetic‐tests‐note‐caution
7. Beard C, Monohan K, Cicciarelli L, James PA. Mainstream genetic testing for breast cancer patients: early experiences from the Parkville Familial Cancer Centre. Eur J Hum Genet 2021; 29: 872‐880.
8. Kemp Z, Turnbull A, Yost S, et al. Evaluation of cancer‐based criteria for use in mainstream BRCA1 and BRCA2 genetic testing in patients with breast cancer. JAMA Netw Open 2019; 2: e194428.
9. Meiser B, Quinn VF, Mitchell G, et al; TFGT Collaborative Group. Psychological outcomes and surgical decisions after genetic testing in women newly diagnosed with breast cancer with and without a family history. Eur J Hum Genet 2018; 26: 972‐983.
10. Quinn VF, Meiser B, Kirk J, et al. Streamlined genetic education is effective in preparing women newly diagnosed with breast cancer for decision making about treatment‐focused genetic testing: a randomized controlled noninferiority trial. Genet Med 2017; 19: 448‐456.
11. Beitsch PD, Whitworth PW, Hughes K, et al. Underdiagnosis of hereditary breast cancer: are genetic testing guidelines a tool or an obstacle? J Clin Oncol 2019; 37: 453‐460.
12. Whitworth PW, Beitsch PD, Patel R, et al. Clinical utility of universal germline genetic testing for patients with breast cancer. JAMA Netw Open 2022; 5: e2232787.
13. Douma KFL, Meiser B, Kirk J, et al. Health professionals’ evaluation of delivering treatment‐focused genetic testing to women newly diagnosed with breast cancer. Fam Cancer 2015; 14: 265‐272.
14. Scheinberg T, Young A, Woo H, et al. Mainstream consent programs for genetic counseling in cancer patients: a systematic review. Asia Pac J Clin Oncol 2021; 17: 163‐177.
15. National Comprehensive Cancer Network. Genetic/familial high‐risk assessment: breast, ovarian, and pancreatic (NCCN clinical practice guidelines in oncology; version 3.2023). https://www.nccn.org/guidelines/guidelines‐detail?category=2&id=1503 (viewed Feb 2023).
16. Association for Clinical Genomic Science. ACGS best practice guidelines for variant classification in rare disease. 4 Feb 2020. https://www.acgs.uk.com/media/11631/uk‐practice‐guidelines‐for‐variant‐classification‐v4‐01‐2020.pdf (viewed Feb 2023).
17. Lovibond PF, Lovibond SH. The structure of negative emotional states: comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behav Res Ther 1995; 33: 335‐343.
18. Thewes B, Zachariae R, Christensen S, et al. The Concerns About Recurrence Questionnaire: validation of a brief measure of fear of cancer recurrence amongst Danish and Australian breast cancer survivors. J Cancer Surviv 2015; 9: 68‐79.
19. Brehaut JC, O'Connor AM, Wood TJ, et al. Validation of a decision regret scale. Med Decis Making 2003; 23: 281‐292.
20. Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap): a metadata‐driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42: 377‐381.
21. Harbeck N, Penault‐Llorca F, Cortes J, et al. Breast cancer. Nat Rev Dis Primers 2019; 5: 66.
22. Tutt ANJ, Garber JE, Kaufman B, et al; OlympiA Clinical Trial Steering Committee and Investigators. Adjuvant olaparib for patients with BRCA1‐ or BRCA2‐mutated breast cancer. N Engl J Med 2021; 384: 2394‐2405.
23. Yang S, Axilbund JE, O'Leary E, et al. Underdiagnosis of hereditary breast and ovarian cancer in Medicare patients: genetic testing criteria miss the mark. Ann Surg Oncol 2018; 25: 2925‐2931.
24. Mersch J, Brown N, Pirzadeh‐Miller S, et al. Prevalence of variant reclassification following hereditary cancer genetic testing. JAMA 2018; 320: 1266‐1274.
25. Hu C, Hart SN, Gnanaolivu R, et al. A population‐based study of genes previously implicated in breast cancer. N Engl J Med 2021; 384: 440‐451.
26. Foulkes WD. The ten genes for breast (and ovarian) cancer susceptibility. Nature Rev Clin Oncol 2021; 28: 259‐260.
27. Sun L, Brentnall A, Patel S, et al. A cost‐effectiveness analysis of multigene testing for all patients with breast cancer. JAMA Oncol 2019; 5: 1718‐1730.
28. Australian Institute of Health and Welfare. Cancer data in Australia (Cat. no. CAN 122). Updated 4 Oct 2022. https://www.aihw.gov.au/reports/cancer/cancer‐data‐in‐australia/contents/about (viewed Feb 2023).

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The characteristics of SARS‐CoV‐2‐positive children in Australian hospitals: a PREDICT network study

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Long COVID in Australia: achieving equitable access to supportive health care

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Upholding our rights in research: calling for urgent investment in Aboriginal and Torres Strait Islander health research ethics

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Commercial determinants of human rights: for‐profit health care and housing

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The impact on poisonings of up‐scheduling of modified release paracetamol to Schedule 3 (pharmacist only medicine)

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Comparison of performance outcomes after general practice training in remote and rural or regional locations in Australia

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The diagnosis and initial management of melanoma in Australia: findings from the prospective, population‐based QSkin study

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Universal genetic testing for women with newly diagnosed breast cancer in the context of multidisciplinary team care

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Mental health and wellbeing of health and aged care workers in Australia, May 2021 – June 2022: a longitudinal cohort study

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Introducing Australia's clinical care standard for low back pain

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The characteristics of SARS‐CoV‐2‐positive children in Australian hospitals: a PREDICT network study

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Long COVID in Australia: achieving equitable access to supportive health care

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Upholding our rights in research: calling for urgent investment in Aboriginal and Torres Strait Islander health research ethics

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Commercial determinants of human rights: for‐profit health care and housing

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The impact on poisonings of up‐scheduling of modified release paracetamol to Schedule 3 (pharmacist only medicine)

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Comparison of performance outcomes after general practice training in remote and rural or regional locations in Australia

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The diagnosis and initial management of melanoma in Australia: findings from the prospective, population‐based QSkin study

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Universal genetic testing for women with newly diagnosed breast cancer in the context of multidisciplinary team care

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Mental health and wellbeing of health and aged care workers in Australia, May 2021 – June 2022: a longitudinal cohort study

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Introducing Australia's clinical care standard for low back pain

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Pagination