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    Radiation therapy and early breast cancer: current controversies

    John Boyages
    Med J Aust 2017; 207 (5): . || doi: 10.5694/mja16.01020
    Published online: 4 September 2017

    Summary

     

    • Radiation therapy (RT) is an important component of breast cancer treatment.
    • RT reduces local recurrence and breast cancer mortality after breast conservation for all patients and for node-positive patients after a mastectomy.
    • Short courses of RT over 3–4 weeks are generally as effective as longer courses.
    • A patient subgroup where RT can be avoided after conservative surgery has not been consistently identified.
    • A radiation boost reduces the risk of a recurrence in the breast but may be omitted for older patients with good prognosis tumours with clear margins.
    • Axillary recurrences can take a long time to appear, with 35% occurring after 5 years.
    • Leaving disease untreated in regional nodes is associated with reduced survival.
    • Not all patients require radiation after neoadjuvant chemotherapy and a subsequent mastectomy.
    • Modern RT equipment and techniques will further improve survival rates.

     

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      Non-coeliac gluten or wheat sensitivity: emerging disease or misdiagnosis?

      Michael DE Potter, Marjorie M Walker and Nicholas J Talley
      Med J Aust 2017; 207 (5): . || doi: 10.5694/mja17.00332
      Published online: 4 September 2017

      Summary

       

      • Non-coeliac gluten or wheat sensitivity (NCG/WS) is a condition characterised by adverse gastrointestinal and/or extra-intestinal symptoms associated with the ingestion of gluten- or wheat-containing foods, in the absence of coeliac disease or wheat allergy.
      • Up to one in 100 people in Australia may have coeliac disease but many more report adverse gastrointestinal and/or extra-intestinal symptoms after eating wheat products.
      • In the absence of validated biomarkers, a diagnosis of NCG/WS can only be made by a double-blind, placebo-controlled, dietary crossover challenge with gluten, which is difficult to apply in clinical practice.
      • Of people self-reporting gluten or wheat sensitivity, only a small proportion (16%) will have reproducible symptoms after a blinded gluten challenge of gluten versus placebo in a crossover dietary trial and fulfil the current consensus criteria for a diagnosis of NCG/WS.
      • A wide range of symptoms are associated with NCG/WS, including gastrointestinal, neurological, psychiatric, rheumatological and dermatological complaints.
      • The pathogenesis of NCG/WS is not well understood, but the innate immune system has been implicated, and there is overlap with coeliac disease and the functional gastrointestinal disorders (irritable bowel syndrome and functional dyspepsia).
      • Identification of NCG/WS is important as gluten-free diets carry risks, are socially restricting and are costlier than regular diets.

       

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      • 1 University of Newcastle, Newcastle, NSW
      • 2 Medical Journal of Australia, Sydney, NSW


      Competing interests:

      Nicholas Talley is Editor-in-Chief of the Medical Journal of Australia.

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        Testing for type 2 diabetes in Indigenous Australians: guideline recommendations and current practice

        Christine L Paul, Paul Ishiguchi, Catherine A D'Este, Jonathan E Shaw, Rob W Sanson-Fisher, Kristy Forshaw, Alessandra Bisquera, Jennifer Robinson, Claudia Koller and Sandra J Eades
        Med J Aust 2017; 207 (5): . || doi: 10.5694/mja16.00769
        Published online: 4 September 2017

        Abstract

        Objectives: To determine the proportion of Aboriginal Controlled Community Health Service (ACCHS) patients tested according to three national diabetes testing guidelines; to investigate whether specific patient characteristics were associated with being tested.

        Design, setting and participants: Cross-sectional study of 20 978 adult Indigenous Australians not diagnosed with diabetes attending 18 ACCHSs across Australia. De-identified electronic whole service data for July 2010 – June 2013 were analysed.

        Main outcomes measures: Proportions of patients appropriately screened for diabetes according to three national guidelines for Indigenous Australians: National Health and Medical Research Council (at least once every 3 years for those aged 35 years or more); Royal Australian College of General Practitioners and Diabetes Australia (at least once every 3 years for those aged 18 years or more); National Aboriginal Community Controlled Health Organisation (annual testing of those aged 18 years or more at high risk of diabetes).

        Results: 74% (95% CI, 74–75%) of Indigenous adults and 77% (95% CI, 76–78%) of 10 760 patients aged 35 or more had been tested for diabetes at least once in the past 3 years. The proportions of patients tested varied between services (range: all adults, 16–90%; people aged 35 years or more, 23–92%). 18% (95% CI, 18–19%) of patients aged 18 or more were tested for diabetes annually (range, 0.1–43%). Patients were less likely to be tested if they were under 50 years of age, were transient rather than current patients of the ACCHS, or attended the service less frequently.

        Conclusions: Some services achieved high rates of 3-yearly testing of Indigenous Australians for diabetes, but recommended rates of annual testing were rarely attained. ACCHSs may need assistance to achieve desirable levels of testing.

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        • 1 University of Newcastle, Newcastle, NSW
        • 2 Priority Research Centre for Health Behaviour, University of Newcastle, Newcastle, NSW
        • 3 Hunter Medical Research Institute, Newcastle, NSW
        • 4 Baker IDI Heart and Diabetes Institute, Melbourne, VIC
        • 5 National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT


        Correspondence: chris.paul@newcastle.edu.au
        Acknowledgements: 

        The authors gratefully acknowledge the generous support of the staff and patients from the following Aboriginal Community Controlled Health Services (in alphabetical order): Anyinginyi Health Aboriginal Corporation, Bega Garnbirringu Aboriginal Health Service, Danila Dilba Biluru Butji Binnilutum Health Service, Derbarl Yerrigan Health Service, Dhauwurd-Wurrung Elderly and Community Health Service, Kirrae Aboriginal Health Service, Mawarnkarra Health Service, Mildura Aboriginal Corporation, Mitwatj Health Aboriginal Corporation, Pika Wiya Health Service, Riverina Medical and Dental Aboriginal Corporation, South West Aboriginal Medical Service, Sunrise Health Service Aboriginal Corporation, Umoona Tjutagku Health Service, Winnunga Nimmityajah Aboriginal Health Service, Ampilatwatja Health Centre Aboriginal Corporation, Pius X Aboriginal Corporation, and Victorian Aboriginal Health Service.

        Competing interests:

        No relevant disclosures.

        • 1. Australian Institute of Health and Welfare. Diabetes and disability: impairments, activity limitations, participation restrictions and comorbidities (AIHW Cat. No. CVD 63; Diabetes Series No. 20). Canberra: AIHW, 2013.
        • 2. Public Health Agency of Canada. Diabetes in Canada: facts and figures from a public health perspective. Ottawa: Chronic Disease Surveillance and Monitoring Division, 2011. http://www.phac-aspc.gc.ca/cd-mc/publications/diabetes-diabete/facts-figures-faits-chiffres-2011/index-eng.php (accessed June 2017).
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          Implementing change: evaluating the Accelerated Chest pain Risk Evaluation (ACRE) project

          William A Parsonage, Tanya Milburn, Sarah Ashover, Wade Skoien, Jaimi H Greenslade, Louise McCormack and Louise Cullen
          Med J Aust 2017; 207 (5): . || doi: 10.5694/mja16.01479
          Published online: 4 September 2017

          Abstract

          Objective: To evaluate hospital length of stay (LOS) and admission rates before and after implementation of an evidence-based, accelerated diagnostic protocol (ADP) for patients presenting to emergency departments (EDs) with chest pain.

          Design: Quasi-experimental design, with interrupted time series analysis for the period October 2013 – November 2015.

          Setting, participants: Adults presenting with chest pain to EDs of 16 public hospitals in Queensland.

          Intervention: Implementation of the ADP by structured clinical re-design.

          Main outcome measures: Primary outcome: hospital LOS. Secondary outcomes: ED LOS, hospital admission rate, proportion of patients identified as being at low risk of an acute coronary syndrome (ACS).

          Results: Outcomes were recorded for 30 769 patients presenting before and 23 699 presenting after implementation of the ADP. Following implementation, 21.3% of patients were identified by the ADP as being at low risk for an ACS. Following implementation of the ADP, mean hospital LOS fell from 57.7 to 47.3 hours (rate ratio [RR], 0.82; 95% CI, 0.74–0.91) and mean ED LOS for all patients presenting with chest pain fell from 292 to 256 minutes (RR, 0.80; 95% CI, 0.72–0.89). The hospital admission rate fell from 68.3% (95% CI, 59.3–78.5%) to 54.9% (95% CI, 44.7–67.6%; P < 0.01). The estimated release in financial capacity amounted to $2.3 million as the result of reduced ED LOS and $11.2 million through fewer hospital admissions.

          Conclusions: Implementing an evidence-based ADP for assessing patients with chest pain was feasible across a range of hospital types, and achieved a substantial release of health service capacity through reductions in hospital admissions and ED LOS.

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          • 1 Royal Brisbane and Women's Hospital, Brisbane, QLD
          • 2 Queensland University of Technology, Brisbane, QLD
          • 3 The University of Queensland, Brisbane, QLD


          Correspondence: w.parsonage@mac.com
          Acknowledgements: 

          The ACRE Project was funded by the Queensland Government Department of Health. We acknowledge the support of the Healthcare Improvement Unit, Queensland Department of Health. We thank the Queensland Research Linkage Group of the Department of Health for assistance with linking data from the emergency department and inpatient datasets. We also gratefully acknowledge the contributions of former project officers Jennifer Bilesky, Jo Sippel and Vandana Bettens in the early development of the project, and the staff of the participating hospitals.

          Competing interests:

          No relevant disclosures.

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          • 14. Fanaroff AC, Schulteis RD, Pieper KS, et al. Simplified predictive instrument to rule out acute coronary syndromes in a high-risk population. J Am Heart Assoc 2015; 4: e002351.
          • 15. Roffi M, Patrono C, Collet JP, et al. Task Force for the Management of Acute Coronary Syndromes in Patients Presenting without Persistent ST-Segment Elevation of the European Society of Cardiology (ESC). 2015 ESC guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. Eur Heart J 2016; 37: 267-315.
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            Statistical and clinical significance

            Ian A Scott
            Med J Aust 2017; 207 (5): . || doi: 10.5694/mja16.01148
            Published online: 4 September 2017

            In published research, a statistically significant result is often wrongly interpreted as representing a clinically important finding. In this article, we explore the meanings of statistical and clinical significance.


            • 1 Princess Alexandra Hospital, Brisbane, QLD
            • 2 University of Queensland, Brisbane, QLD


            Correspondence: ian.scott@health.qld.gov.au
            Competing interests:

            No relevant disclosures.

            • 1. Jones MP, Beath A, Oldmeadow C, Attia JR. Understanding statistical hypothesis tests and power. Med J Aust 2017; 207: 148-150. <MJA full text>
            • 2. Akobeng AK. Understanding type I and type II errors, statistical power and sample size. Acta Paediatr 2016; 105: 605-609.
            • 3. Furukawa TA, Scott IA, Guyatt G. Chapter 12.5: Measuring patients’ experience. In: Guyatt G, Rennie D, Meade MO, Cook DJ, editors. Users’ guides to the medical literature. A manual for evidence-based practice. 3rd ed. Boston: JAMA Press, 2015: pp. 219-234.
            • 4. Pocock SJ, Ware JH. Translating statistical findings into plain English. Lancet 2009; 373: 1926-1928.
            • 5. Gardner MJ, Altman DG. Confidence intervals rather than P values: estimation rather than hypothesis testing. BMJ 1986; 292: 746-750.
            • 6. Pocock SJ, Stone GW. The primary outcome is positive – is that good enough? N Engl J Med 2016; 375: 971-979.
            • 7. Pocock J, Stone GW. The primary outcome fails – what next? N Engl J Med 2016; 375: 861-870.
            • 8. Montori VM, Devereaux PJ, Adhikari NK, et al. Randomized trials stopped early for benefit: a systematic review. JAMA 2005; 294: 2203-2209.
            • 9. Mulla SM, Scott IA, Jackevicius CA, et al. User’s guide to the medical literature. How to use a non-inferiority trial. JAMA 2012; 308: 2605-2611.
            • 10. Seruga B, Templeton AJ, Badillo FE, et al. Under-reporting of harm in clinical trials. Lancet Oncol 2016; 17: e209-e219.
            • 11. Liao JM, Stack CB, Griswold ME, Localio AR. Understanding clinical research: intention to treat analysis. Ann Intern Med 2017; 166: 662-664.
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              Improving the safety of breast implants: implant-associated lymphoma

              Ingrid Hopper, Susannah Ahern, John J McNeil, Anand K Deva, Elisabeth Elder, Colin Moore and Rodney Cooter
              Med J Aust 2017; 207 (5): . || doi: 10.5694/mja17.00005
              Published online: 28 August 2017

              A likely causal link between breast implants and lymphoma highlights the importance of a prospective registry

              Breast devices, including implants and tissue expanders, are classified as class III (high risk) medical devices by the Therapeutic Goods Administration, and are subject to the highest level of regulatory control. They have been associated with highly publicised health scares in the past, particularly, the Poly Implant Prothèse crisis.1 More recently, breast implants have again created national concern, with the Therapeutic Goods Administration confirming in late 2016 that there were 46 reports of breast implant-associated anaplastic large cell lymphoma (BIA-ALCL) in Australia, including three cases that resulted in death. This number has since increased to 53.2 Most breast implants are used in young women and in women who have had breast cancer, thus long term exposure to these devices can be anticipated. It is therefore imperative to identify serious adverse effects at the earliest opportunity. The Australian Breast Device Registry is ideally positioned to do this, but it requires sufficient resources and engagement to ensure that it remains fit for purpose.


              • 1 Monash University, Melbourne, VIC
              • 2 University of Melbourne, Melbourne, VIC
              • 3 Macquarie University, Sydney, NSW
              • 4 Integrated Specialist Healthcare, Sydney, NSW
              • 5 Westmead Breast Cancer Institute, Sydney, NSW
              • 6 Breast Surgeons of Australia and New Zealand, Sydney, NSW
              • 7 Australasian College of Cosmetic Surgery, Sydney, NSW
              • 8 Australasian Foundation for Plastic Surgery, Sydney, NSW


              Correspondence: Ingrid.Hopper@monash.edu
              Acknowledgements: 

              The Department of Health provides funding for the Australian Breast Device Registry. Ingrid Hopper is supported by a National Health and Medical Research Council early career fellowship.

              Competing interests:

              No relevant disclosures.

              • 1. Jeeves AE, Cooter RD. Transforming Australia’s Breast Implant Registry. Med J Aust 2012; 196: 232-234. <MJA full text>
              • 2. Therapeutic Goods Administration. Breast implants and anaplastic large cell lymphoma. https://www.tga.gov.au/alert/breast-implants (accessed July 2017).
              • 3. Brody GS, Deapen D, Taylor CR, et al. Anaplastic large cell lymphoma occurring in women with breast implants: analysis of 173 cases. Plast Reconstr Surg 2015; 135: 695-705.
              • 4. Prince HM, Johnstone R. Commentary on: biomarkers provide clues to early events in the pathogenesis of breast implant-associated anaplastic large cell lymphoma. Aesthet Surg J 2016; 36: 782-783.
              • 5. Loch-Wilkison A, Beath K, Knight RJW, et al. Breast implant associated anaplastic large cell lymphoma in Australia and New Zealand – high surface area textured implants are associated with increased risk. Plast Reconstr Surg 2017; doi: 10.1097/PRS.0000000000003654 [Epub ahead of print].
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              • 8. Hu H, Jacombs A, Vickery K, et al. Chronic biofilm infection in breast implants is associated with an increased T-cell lymphocytic infiltrate: implications for breast implant-associated lymphoma. Plast Reconstr Surg 2015; 135: 319-329.
              • 9. Blombery P, Thompson ER, Jones K, et al. Whole exome sequencing reveals activating JAK1 and STAT3 mutations in breast-implant associated anaplastic large cell lymphoma. Haematologica 2016; 10: e387-e390.
              • 10. Hopper I, Ahern S, Best RL, et al. Australian Breast Device Registry: breast device safety transformed. ANZ J Surg 2017; 87: 9-10.
              • 11. Deva AK, Adams WP, Vickery K. The role of bacterial biofilms in device-associated infection. Plast Reconstr Surg 2013; 132: 1319-1328.
              • 12. de Steiger RN, Hang JR, Miller LN, et al. Five-year results of the ASR XL Acetabular System and the ASR Hip Resurfacing System: an analysis from the Australian Orthopaedic Association National Joint Replacement Registry. J Bone Joint Surg Am 2011; 93: 2287-2293.
              • 13. van der Veer SN, de Keizer NF, Ravelli AC, et al. Improving quality of care. A systematic review on how medical registries provide information feedback to health care providers. Int J Med Inform 2010; 79: 305-323.
              • 14. Sedrakyan A, Campbell B, Graves S, Cronenwett JL. Surgical registries for advancing quality and device surveillance. Lancet 2016; 388: 1358-1360.
              • 15. Cooter RD, Barker S, Carroll SM, et al. International importance of robust breast device registries. Plast Reconstr Surg 2015; 135: 330-336.
              Online responses are no longer available. Please refer to our instructions for authors page for more information.

                Coeliac disease: review of diagnosis and management

                Marjorie M Walker, Jonas F Ludvigsson and David S Sanders
                Med J Aust 2017; 207 (4): . || doi: 10.5694/mja16.00788
                Published online: 21 August 2017

                Summary

                 

                • Coeliac disease is an immune-mediated systemic disease triggered by exposure to gluten, and manifested by small intestinal enteropathy and gastrointestinal and extra-intestinal symptoms. Recent guidelines recommend a concerted use of clear definitions of the disease.
                • In Australia, the most recent estimated prevalence is 1.2% in adult men (1:86) and 1.9% in adult women (1:52). Active case finding is appropriate to diagnose coeliac disease in high risk groups. Diagnosis of coeliac disease is important to prevent nutritional deficiency and long term risk of gastrointestinal malignancy.
                • The diagnosis of coeliac disease depends on clinico-pathological correlation: history, presence of antitransglutaminase antibodies, and characteristic histological features on duodenal biopsy (when the patient is on a gluten-containing diet). Human leucocyte antigen class II haplotypes DQ2 or DQ8 are found in nearly all patients with coeliac disease, but are highly prevalent in the general population at large (56% in Australia) and testing can only exclude coeliac disease for individuals with non-permissive haplotypes.
                • Adhering to a gluten free diet allows duodenal mucosal healing and alleviates symptoms. Patients should be followed up with a yearly review of dietary adherence and a health check.
                • Non-coeliac gluten or wheat protein sensitivity is a syndrome characterised by both gastrointestinal and extra-intestinal symptoms related to the ingestion of gluten and possibly other wheat proteins in people who do not have coeliac disease or wheat allergy recognised by diagnostic tests.

                 


                • 1 University of Newcastle, Newcastle, NSW
                • 2 Karolinksa Institutet, Stockholm, Sweden
                • 3 Royal Hallamshire Hospital, Sheffield, United Kingdom


                Competing interests:

                No relevant disclosures.

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                  Opting for rural practice: the influence of medical student origin, intention and immersion experience

                  Denese Playford, Hanh Ngo, Surabhi Gupta and Ian B Puddey
                  Med J Aust 2017; 207 (4): . || doi: 10.5694/mja16.01322
                  Published online: 21 August 2017

                  Abstract

                  Objective: To compare the influence of rural background, rural intent at medical school entry, and Rural Clinical School (RCS) participation on the likelihood of later participation in rural practice.

                  Design: Analysis of linked data from the Medical School Outcomes Database Commencing Medical Students Questionnaire (CMSQ), routinely collected demographic information, and the Australian Health Practitioner Regulation Agency database on practice location.

                  Setting and participants: University of Western Australia medical students who completed the CMSQ during 2006–2010 and were practising medicine in 2016.

                  Main outcome measures: Medical practice in rural areas (ASGC-RAs 2–5) during postgraduate years 2–5.

                  Results: Full data were available for 508 eligible medical graduates. Rural background (OR, 3.91; 95% CI, 2.12–7.21; P < 0.001) and experience in an RCS (OR, 1.93; 95% CI, 1.05–3.54; P = 0.034) were significant predictors of rural practice in the multivariate analysis of all potential factors. When interactions between intention, origin, and RCS experience were included, RCS participation significantly increased the likelihood of graduates with an initial rural intention practising in a rural location (OR, 3.57; 95% CI, 1.25–10.2; P = 0.017). The effect of RCS participation was not significant if there was no pre-existing intention to practise rurally (OR, 1.38; 95% CI, 0.61–3.16; P = 0.44).

                  Conclusion: For students who entered medical school with the intention to later work in a rural location, RCS experience was the deciding factor for realising this intention. Background, intent and RCS participation should all be considered if medical schools are to increase the proportion of graduates working rurally.

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                  • 1 The Rural Clinical School of Western Australia, University of Western Australia, Perth, WA
                  • 2 University of Western Australia, Perth, WA


                  Correspondence: denese.playford@uwa.edu.au
                  Acknowledgements: 

                  We acknowledge the statistical advice of Sharon Evans, senior biostatistician, and the support of David Atkinson, head of the Rural Clinical School of Western Australia.

                  Competing interests:

                  No relevant disclosures.

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                    Digital rectal examination: indications and technique

                    Christopher S Pokorny
                    Med J Aust 2017; 207 (4): . || doi: 10.5694/mja17.00373
                    Published online: 21 August 2017

                    Digital rectal examination (DRE) is an important component of the physical examination. It is essential when someone presents with rectal bleeding, acute abdominopelvic pain (to check for pelvic peritoneal irritation) or other symptoms suggestive of anorectal or prostatic pathology (Box 1). Indeed, in days gone by, some physicians lived by the maxim: “if you don’t put your finger in, you put your foot in it” (attributed to Hamilton Bailey, English surgeon, 1894–1961).


                    • South Western Sydney Medical School, UNSW Sydney, Sydney, NSW


                    Correspondence: c.pokorny@unsw.edu.au
                    Competing interests:

                    No relevant disclosures.

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                    • 3. Talley NJ. How to do and interpret a rectal examination in gastroenterology. Am J Gastroenterol 2008; 103: 820-822.
                    • 4. Hoepffner N, Shastri YM, Hanisch E, et al. Comparative evaluation of a new bedside faecal occult blood test in a prospective multicentre study. Aliment Pharmacol Ther 2006; 23: 145-154.
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                      No smoker left behind: it’s time to tackle tobacco in Australian priority populations

                      Billie Bonevski, Ron Borland, Christine L Paul, Robyn L Richmond, Michael Farrell, Amanda Baker, Coral E Gartner, Sharon Lawn, David P Thomas and Natalie Walker
                      Med J Aust 2017; 207 (4): . || doi: 10.5694/mja16.01425
                      Published online: 21 August 2017

                      A truly comprehensive approach to tobacco control should include interventions targeting high risk groups

                      Australia is a world leader in tobacco control as a result of implementing the strong tobacco control strategies in the World Health Organization Framework Convention on Tobacco Control (http://www.who.int/fctc/en). The Australian adult daily smoking prevalence is 14%1 compared with 31% in 1986,2 with a government goal to reduce this prevalence to 10% by 2020.3 Recently employed tobacco control strategies include increased taxation and plain cigarette pack legislation, supported by strong legislative, economic and community commitment to significantly reduce tobacco use in our society. These strategies motivate smokers to quit. For example, data from the 2007 National Drug Strategy Household Survey4 indicate that high cigarette prices are a key motivator to attempt to quit or reduce the number of cigarettes smoked.


                      • 1 University of Newcastle, Newcastle, NSW
                      • 2 Cancer Council Victoria, Melbourne, VIC
                      • 3 UNSW Sydney, Sydney, NSW
                      • 4 National Drug and Alcohol Research Centre, UNSW Sydney, Sydney, NSW
                      • 5 University of Queensland, Brisbane, QLD
                      • 6 Flinders Human Behaviour and Health Research Unit, Flinders University, Adelaide, SA
                      • 7 Menzies School of Health Research, Darwin, NT
                      • 8 National Institute for Health Innovation, University of Auckland, Auckland, NZ


                      Competing interests:

                      No relevant disclosures.

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                      • 2. Greenhalgh EM, Bayly M, Winstanley MH. 1.3 Prevalence of smoking—adults. In: Scollo MM, Winstanley MH, editors. Tobacco in Australia: facts and issues. Melbourne: Cancer Council Victoria, 2015. http://www.tobaccoinaustralia.org.au/chapter-1-prevalence/1-3-prevalence-of-smoking-adults (accessed July 2017).
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                      Online responses are no longer available. Please refer to our instructions for authors page for more information.
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