Specialist Palliative Care and Health Care Costs at the End of Life

BACKGROUND/AIMS

The use and costs of health care rise substantially in the months prior to death, and although the use of palliative care services may be expected to lead to less costly care, the evidence is mixed. We analysed the costs of care over the last year of life and the extent to which these are associated with the use and duration of specialist palliative care (SPC) for decedents who died from cancer or another life-limiting illness.

METHODS

The decedents were participants in a cohort study of older residents of the state of New South Wales, Australia. Using linked survey and administrative health data from 2007 to 2016, two cohorts were identified: n = 10,535 where the cause of death was cancer; and n = 11,179 where the cause of death was another life-limiting illness. Costs of various types were analysed with separate risk-adjusted linear regression models for the last 1, 3, 6, 9 and 12 months before death and for both cohorts. SPC was categorised according to time to death from first contact with the service as 1-7 days, 7-30 days, 30-180 days and more than 180 days.

RESULTS

SPC use was higher among the cancer cohort (30.0%) relative to the non-cancer cohort (4.8%). The mean costs over the final year of life were AU$55,037 (SD 45,059) for the cancer cohort and AU$35,318 (SD 41,948) for the non-cancer cohort. Earlier use of SPC was associated with higher costs over the last year of life but lower costs in the last 1 and 3 months for both cohorts. Initiating SPC use more than 180 days before death was associated with a mean difference relative to the no SPC group of AU$15,590 (95% CI 10,617 to 20,562) and AU$13,739 (95% CI 733 to 26,746) over the last year of life for those dying from cancer and another illness, respectively. The same differences over the last month of life were - AU$2810 (95% CI -  3945 to -  1676) and - AU$4345 (95% CI -  6625 to - 2066). Admitted hospital care was the major driver of costs, with longer SPC associated with lower rates of death in hospital for both cohorts.

CONCLUSION

Early initiation of SPC was associated with higher costs over the last year of life and lower costs over the last months of life. This was the case for both the cancer and non-cancer cohorts, and appeared to be largely attributed to reduced hospitalisation. Although further investigation is required, our results suggest that expanding the availability of SPC services to provide more equitable access could enable patients to spend more time at their usual place of residence, reduce pressure on inpatient services and facilitate death at home when that is preferred.

Acceptability and appropriateness of a risk-tailored organised melanoma screening program: Qualitative interviews with key informants

INTRODUCTION

In Australia, opportunistic screening (occurring as skin checks) for the early detection of melanoma is common, and overdiagnosis is a recognised concern. Risk-tailored cancer screening is an approach to cancer control that aims to provide personalised screening tailored to individual risk. This study aimed to explore the views of key informants in Australia on the acceptability and appropriateness of risk-tailored organised screening for melanoma, and to identify barriers, facilitators and strategies to inform potential future implementation. Acceptability and appropriateness are crucial, as successful implementation will require a change of practice for clinicians and consumers.

METHODS

This was a qualitative study using semi-structured interviews. Key informants were purposively selected to ensure expertise in melanoma early detection and screening, prioritising senior or executive perspectives. Consumers were expert representatives. Data were analysed deductively using the Tailored Implementation for Chronic Diseases (TICD) checklist.

RESULTS

Thirty-six participants were interviewed (10 policy makers; 9 consumers; 10 health professionals; 7 researchers). Key informants perceived risk-tailored screening for melanoma to be acceptable and appropriate in principle. Barriers to implementation included lack of trial data, reluctance for low-risk groups to not screen, variable skill level in general practice, differing views on who to conduct screening tests, confusing public health messaging, and competing health costs. Key facilitators included the perceived opportunity to improve health equity and the potential cost-effectiveness of a risk-tailored screening approach. A range of implementation strategies were identified including strengthening the evidence for cost-effectiveness, engaging stakeholders, developing pathways for people at low risk, evaluating different risk assessment criteria and screening delivery models and targeted public messaging.

CONCLUSION

Key informants were supportive in principle of risk-tailored melanoma screening, highlighting important next steps. Considerations around risk assessment, policy and modelling the costs of current verses future approaches will help inform possible future implementation of risk-tailored population screening for melanoma.

Clinical Utility Assessment of a Nursing Checklist Identifying Complex Care Needs Due to Inequities Among Ambulatory Patients With Cancer: Protocol for a Mixed Methods Study

BACKGROUND

Disparities in cancer incidence, complex care needs, and poor health outcomes are largely driven by structural inequities stemming from social determinants of health. To date, no evidence-based clinical tool has been developed to identify newly diagnosed patients at risk of poorer outcomes. Specialist cancer nurses are well-positioned to ameliorate inequity of opportunity for optimal care, treatment, and outcomes through timely screening, assessment, and intervention. We designed a nursing complexity checklist (the "Checklist") to support these activities, with the ultimate goal of improving equitable experiences and outcomes of care. This study aims to generate evidence regarding the clinical utility of the Checklist.

OBJECTIVE

The primary objectives of this study are to provide qualitative evidence regarding key aspects of the Checklist's clinical utility (appropriateness, acceptability, and practicability), informed by Smart's multidimensional model of clinical utility. Secondary objectives explore the predictive value of the Checklist and concordance between specific checklist items and patient-reported outcome measures.

METHODS

This prospective mixed methods case series study will recruit up to 60 newly diagnosed patients with cancer and 10 specialist nurses from a specialist cancer center. Nurses will complete the Checklist with patient participants. Within 2 weeks of Checklist completion, patients will complete 5 patient-reported outcome measures with established psychometric properties that correspond to specific checklist items and an individual semistructured interview to explore Checklist clinical utility. Interviews with nurses will occur 12 and 24 weeks after they first complete a checklist, exploring perceptions of the Checklist's clinical utility including barriers and facilitators to implementation. Data describing planned and unplanned patient service use will be collected from patient follow-up interviews at 12 weeks and the electronic medical record at 24 weeks after Checklist completion. Descriptive statistics will summarize operational, checklist, and electronic medical record data. The predictive value of the Checklist and the relationship between specific checklist items and relevant patient-reported outcome measures will be examined using descriptive statistics, contingency tables, measures of association, and plots as appropriate. Qualitative data will be analyzed using a content analysis approach.

RESULTS

This study was approved by the institution's ethics committee. The enrollment period commenced in May 2022 and ended in November 2022. In total, 37 patients with cancer and 7 specialist cancer nurses were recruited at this time. Data collection is scheduled for completion at the end of May 2023.

CONCLUSIONS

This study will evaluate key clinical utility dimensions of a nursing complexity checklist. It will also provide preliminary evidence on its predictive value and information to support its seamless implementation into everyday practice including, but not limited to, possible revisions to the Checklist, instructions, and training for relevant personnel. Future implementation of this Checklist may improve equity of opportunity of access to care for patients with cancer.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/48432.

Higher fees and out-of-pocket costs in radiotherapy point to a need for funding reform

ObjectiveTo elucidate the policy implications of recent trends in the funding of radiotherapy services between 2009-10 and 2021-22.MethodWe use national aggregate claims data to determine time trends in the fees, benefits and out-of-pocket (OOP) costs of radiotherapy and nuclear therapeutic medicine claims funded through the Medicare Benefits Schedule (MBS) program. All dollar figures are expressed in constant 2021 Australian dollars.ResultsRadiotherapy and nuclear therapeutic medicine MBS claims increased by 78% whereas MBS funding increased by 137% between 2009-10 and 2021-22. The main driver of Medicare funding growth has been the Extended Medicare Safety Net, which has increased by 404%. Over the 13 year observation period, the percentage of bulk-billed claims peaked in 2017-18 at 76.1% but fell to 69.8% in 2021-22. For non-bulk billed services, average OOP costs per claim increased from $20.40 in 2009-10 to $69.78 in 2021-22.ConclusionDespite increased Medicare funding, patients face increasing financial barriers to access radiation oncology services. Policies with regard to funding radiotherapy services should be reviewed to ensure that services are easily accessible and affordable for all those needing treatment and at a reasonable cost to Government.

Skin cancer-related conditions managed in general practice in Australia, 2000-2016: a nationally representative, cross-sectional survey

OBJECTIVE

Skin cancer is Australia's most common and costly cancer. We examined the frequency of Australian general practice consultations for skin cancer-related conditions, by patient and general practitioner (GP) characteristics and by time period.

DESIGN

Nationally representative, cross-sectional survey of general practice clinical activity.

SETTING, PARTICIPANTS

Patients aged 15 years or older having a skin cancer-related condition managed by GPs in the Bettering the Evaluation And Care of Health study between April 2000 and March 2016.

PRIMARY OUTCOME MEASURES

Proportions and rates per 1000 encounters.

RESULTS

In this period, 15 678 GPs recorded 1 370 826 patient encounters, of which skin cancer-related conditions were managed 65 411 times (rate of 47.72 per 1000 encounters, 95% CI 46.41 to 49.02). Across the whole period, 'skin conditions' managed were solar keratosis (29.87%), keratinocyte cancer (24.85%), other skin lesion (12.93%), nevi (10.98%), skin check (10.37%), benign skin neoplasm (8.76%) and melanoma (2.42%). Over time, management rates increased for keratinocyte cancers, skin checks, skin lesions, benign skin neoplasms and melanoma; but remained stable for solar keratoses and nevi. Skin cancer-related encounter rates were higher for patients aged 65-89 years, male, living in Queensland or in regional or remote areas, with lower area-based socioeconomic status, of English-speaking background, Veteran card holders and non-healthcare card holders; and for GPs who were aged 35-44 years or male.

CONCLUSION

These findings show the spectrum and burden of skin cancer-related conditions managed in general practice in Australia, which can guide GP education, policy and interventions to optimise skin cancer prevention and management.

Geographic variation in out-of-pocket costs for radiation oncology services

OBJECTIVES

To examine out-of-pocket costs incurred by patients for radiation oncology services and their variation by geographic location.

DESIGN

Analysis of patient-level Medical Benefits Schedule (MBS) claims data linked with data from the Sax Institute 45 and Up Study.

SETTING, PARTICIPANTS

People who received Medicare-subsidised radiation oncology services in New South Wales, 2006-2017.

MAIN OUTCOME MEASURE

Mean out-of-pocket costs for an episode of radiation oncology (during 90 days from start of radiotherapy planning service), by geographic location (postcode-based), overall and after excluding episodes with no out-of-pocket costs (fully bulk-billed).

RESULTS

During 2006-2017, 12 724 people received 15 506 episodes of radiation oncology care in 25 postcode-defined geographic areas. The proportion of episodes for which the out-of-pocket cost was less than $1 increased from 39% in 2006 to 76% in 2017; the proportion for which out-of-pocket costs exceeded $500 declined from 43% in 2006 to 10% in 2014, before increasing to 17% in 2017. For care episodes with non-zero out-of-pocket costs, the mean amount rose from around $1186 to $1611 per episode of care during 2006-2017. The proportion of radiation oncology episodes bulk-billed exceeded 90% in nine areas; in seven areas, all with exclusively private care provision of radiation oncology, it was 21% or smaller. Within geographic areas, out-of-pocket costs for individual care episodes varied widely; in ten areas with lower bulk-billing rates, the interquartile range for costs ranged from $240 to $1857.

CONCLUSION

Out-of-pocket costs are an important determinant of access to care. Although radiotherapy costs for most people are moderate, some face very high costs, and these vary markedly by location. It is important to ensure that radiation oncology services remain affordable for all people who need treatment.

Strengthening cancer control in the South Pacific through coalition-building: a co-design framework

Background

Cancer is a significant problem for the South Pacific region due to a range of complex health challenges. Currently gaps in diagnosis, treatment and palliative care are significant, and while governmental commitment is strong, economic constrains limit health system strengthening. Alliances have been successful in strengthening non-communicable disease and cancer control policy and services in resource constrained settings. A regional coalition approach has therefore been recommended as an effective solution to addressing many of the challenges for cancer control in the South Pacific. However, evidence regarding the effective mechanisms for development of alliances or coalitions is scarce. This study aimed to 1) create a Coalition Development Framework; 2) assess the use of the Framework in practice to co-design a South Pacific Coalition.

Methods

Creation of the Coalition Development Framework commenced with a scoping review and content analysis of existing literature. Synthesis of key elements formed an evidence-informed step-by-step guide for coalition-building. Application of the Framework comprised consultation and iterative discussions with key South Pacific cancer control stakeholders in Fiji, New Caledonia, Papua New Guinea, Samoa and Tonga. Concurrent evaluation of the Framework utilising Theory of Change (ToC) and qualitative analysis of stakeholder consultations was undertaken.

Findings

The finalised Coalition Development Framework comprised four phases with associated actions and deliverables: engagement, discovery, unification, action and monitoring. Application of the Framework in the South Pacific identified overwhelming support for a Cancer Control Coalition through 35 stakeholder consultations. Framework phases enabled stakeholders to confirm coalition design and purpose, strategic imperatives, structure, local foundations, barriers and facilitators, and priorities for action. ToC and thematic consultation analysis confirmed the Framework to be an effective mechanism to drive engagement, unification and action in alliance-building.

Interpretation

A Coalition to drive cancer control has significant support among key Pacific stakeholders, and establishment can now be commenced. Importantly results confirm the effective application of the Coalition Development Framework in an applied setting. If momentum is continued, and a regional South Pacific Coalition established, the benefits in reducing the burden of cancer within the region will be substantial.

Funding

This work was completed for a Masters of Public Health project. Cancer Council Australia provided project funding.

Why is advance care planning underused in oncology settings? A systematic overview of reviews to identify the benefits, barriers, enablers, and interventions to improve uptake

Background

Advance care planning (ACP) centres on supporting people to define and discuss their individual goals and preferences for future medical care, and to record and review these as appropriate. Despite recommendations from guidelines, rates of documentation for people with cancer are considerably low.

Aim

To systematically clarify and consolidate the evidence base of ACP in cancer care by exploring how it is defined; identifying benefits, and known barriers and enablers across patient, clinical and healthcare services levels; as well as interventions that improve advance care planning and are their effectiveness.

Methods

A systematic overview of reviews was conducted and was prospectively registered on PROSPERO. PubMed, Medline, PsycInfo, CINAHL, and EMBASE were searched for review related to ACP in cancer. Content analysis and narrative synthesis were used for data analysis. The Theoretical Domains Framework (TDF) was used to code barriers and enablers of ACP as well as the implied barriers targeted by each of the interventions.

Results

Eighteen reviews met the inclusion criteria. Definitions were inconsistent across reviews that defined ACP (n=16). Proposed benefits identified in 15/18 reviews were rarely empirically supported. Interventions reported in seven reviews tended to target the patient, even though more barriers were associated with healthcare providers (n=40 versus n=60, respectively).

Conclusion

To improve ACP uptake in oncology settings; the definition should include key categories that clarify the utility and benefits. Interventions need to target healthcare providers and empirically identified barriers to be most effective in improving uptake.

Systematic review registration

https://www.crd.york.ac.uk/prospero/display_record.php?, identifier CRD42021288825.

Women with gynaecological cancer awaiting radiotherapy: Self-reported wellbeing, general psychological distress, symptom distress, sexual function, and supportive care needs

OBJECTIVE

To better serve women with gynaecological cancers, we need a sound understanding of their health, wellbeing and needs. This study sought to explore these issues in a sample of Australian women before commencing curative radiotherapy.

METHODS

We undertook a secondary analysis of baseline data from a supportive care trial (n = 311). Descriptive statistics were used to summarise responses to measures of wellbeing, general psychological distress, symptom distress, sexual function and vaginal changes, and supportive care needs. Pre-specified regression models were used to examine sources of variation in wellbeing and sexual function.

RESULTS

Women reported lower emotional, functional and physical wellbeing than population norms (all p < 0.001). The prevalence of general psychological distress was 31% (95% CI 26-36%). Distress caused by physical symptoms was typically low. Health system and information needs comprised eight of the top ten moderate-to-high supportive care needs. Most women reported no change in interest for physical contact or sex compared to pre-diagnosis, but some sexually active women (16-24%) reported smaller vaginal size, increased dryness, and more pain on intercourse. General psychological distress was a robust marker of poorer wellbeing and sexual function.

CONCLUSIONS

Before radiotherapy, a substantial minority of women with gynaecological cancers experience general psychological distress, reduced wellbeing and moderate-to-high health system and information needs. A model of comprehensive care incorporating assessment of unmet needs, general psychological distress, and sexual issues is recommended. Healthcare providers may require training to elicit and respond to a constellation of interrelated issues and access relevant services for women requiring additional support.

Cancer incidence and mortality in Australia from 2020 to 2044 and an exploratory analysis of the potential effect of treatment delays during the COVID-19 pandemic: a statistical modelling study

BACKGROUND

Long-term projections of cancer incidence and mortality estimate the future burden of cancer in a population, and can be of great use in informing the planning of health services and the management of resources. We aimed to estimate incidence and mortality rates and numbers of new cases and deaths up until 2044 for all cancers combined and for 21 individual cancer types in Australia. We also illustrate the potential effect of treatment delays due to the COVID-19 pandemic on future colorectal cancer mortality rates.

METHODS

In this statistical modelling study, cancer incidence and mortality rates in Australia from 2020 to 2044 were projected based on data up to 2017 and 2019, respectively. Cigarette smoking exposure (1945-2019), participation rates in the breast cancer screening programme (1996-2019), and prostate-specific antigen testing rates (1994-2020) were included where relevant. The baseline projection model using an age-period-cohort model or generalised linear model for each cancer type was selected based on model fit statistics and validation with pre-COVID-19 observed data. To assess the impact of treatment delays during the COVID-19 pandemic on colorectal cancer mortality, we obtained data on incidence, survival, prevalence, and cancer treatment for colorectal cancer from different authorities. The relative risks of death due to system-caused treatment delays were derived from a published systematic review. Numbers of excess colorectal cancer deaths were estimated using the relative risk of death per week of treatment delay and different durations of delay under a number of hypothetical scenarios.

FINDINGS

Projections indicate that in the absence of the COVID-19 pandemic effects, the age-standardised incidence rate for all cancers combined for males would decline over 2020-44, and for females the incidence rate would be relatively stable in Australia. The mortality rates for all cancers combined for both males and females are expected to continuously decline during 2020-44. The total number of new cases are projected to increase by 47·4% (95% uncertainty interval [UI] 35·2-61·3) for males, from 380 306 in 2015-19 to 560 744 (95% UI 514 244-613 356) in 2040-44, and by 54·4% (95% UI 40·2-70·5) for females, from 313 263 in 2015-19 to 483 527 (95% UI 439 069-534 090) in 2040-44. The number of cancer deaths are projected to increase by 36·4% (95% UI 15·3-63·9) for males, from 132 440 in 2015-19 to 180 663 (95% UI 152 719-217 126) in 2040-44, and by 36·6% (95% UI 15·8-64·1) for females, from 102 103 in 2015-19 to 139 482 (95% UI 118 186-167 527) in 2040-44, due to population ageing and growth. The example COVID-19 pandemic scenario of a 6-month health-care system disruption with 16-week treatment delays for colorectal cancer patients could result in 460 (95% UI 338-595) additional deaths and 437 (95% UI 314-570) deaths occurring earlier than expected in 2020-44.

INTERPRETATION

These projections can inform health service planning for cancer care and treatment in Australia. Despite the continuous decline in cancer mortality rates, and the decline or plateau in incidence rates, our projections suggest an overall 51% increase in the number of new cancer cases and a 36% increase in the number of cancer deaths over the 25-year projection period. This means that continued efforts to increase screening uptake and to control risk factors, including smoking exposure, obesity, physical inactivity, alcohol use, and infections, must remain public health priorities.

FUNDING

Partly funded by Cancer Council Australia.

How can hospitals change practice to better implement smoking cessation interventions? A systematic review

Smoking cessation reduces the risk of death, improves recovery, and reduces the risk of hospital readmission. Evidence and policy support hospital admission as an ideal time to deliver smoking-cessation interventions. However, this is not well implemented in practice. In this systematic review, the authors summarize the literature on smoking-cessation implementation strategies and evaluate their success to guide the implementation of best-practice smoking interventions into hospital settings. The CINAHL Complete, Embase, MEDLINE Complete, and PsycInfo databases were searched using terms associated with the following topics: smoking cessation, hospitals, and implementation. In total, 14,287 original records were identified and screened, resulting in 63 eligible articles from 56 studies. Data were extracted on the study characteristics, implementation strategies, and implementation outcomes. Implementation outcomes were guided by Proctor and colleagues' framework and included acceptability, adoption, appropriateness, cost, feasibility, fidelity, penetration, and sustainability. The findings demonstrate that studies predominantly focused on the training of staff to achieve implementation. Brief implementation approaches using a small number of implementation strategies were less successful and poorly sustained compared with well resourced and multicomponent approaches. Although brief implementation approaches may be viewed as advantageous because they are less resource-intensive, their capacity to change practice in a sustained way lacks evidence. Attempts to change clinician behavior or introduce new models of care are challenging in a short time frame, and implementation efforts should be designed for long-term success. There is a need to embrace strategic, well planned implementation approaches to embed smoking-cessation interventions into hospitals and to reap and sustain the benefits for people who smoke.

Developing clinical indicators for oncology: the inaugural cancer care indicator set for the Australian Council on Healthcare Standards

INTRODUCTION

The Australian Council on Healthcare Standards (ACHS) sponsored an expert-led, consensus-driven, four-stage process, based on a modified Delphi methodology, to determine a set of clinical indicators as quality measures of cancer service provision in Australia. This was done in response to requests from institutional health care providers seeking accreditation, which were additional and complementary to the existing radiation oncology set. The steering group members comprised multidisciplinary key opinion leaders and a consumer representative. Five additional participants constituted the stakeholder group, who deliberated on the final indicator set.

METHODS AND RECOMMENDATIONS

An initial meeting of the steering group scoped the high level nature of the desired set. In stage 2, 65 candidate indicators were identified by a literature review and a search of international metrics. These were ranked by survey, based on ease of data accessibility and collectability and clinical relevance. The top 27 candidates were debated by the stakeholder group and culled to a final set of 16 indicators. A user manual was created with indicators mapped to clinical codes. The indicator set was ratified by the Clinical Oncology Society of Australia and is now available for use by health care organisations participating in the ACHS Clinical Indicator Program. This inaugural cancer clinical indicator set covers high level assessment of various critical processes in cancer service provision in Australia. Regular reviews and updates will ensure usability.

CHANGES IN MANAGEMENT AS A RESULT OF THIS STATEMENT

This is the inaugural indicator set for cancer care for use across Australia and internationally under the ACHS Clinical Indicator Program. Multidisciplinary involvement through a modified Delphi process selected indicators representing both generic and specific aspects of care across the cancer journey pathway and will provide a functional tool to compare health care delivery across multiple settings. It is anticipated that this will drive continual improvement in cancer care provision.

Development of the 'REadiness SElf-assessment (RESEA) guide' to assist low and middle-income countries with establishing safe and sustainable radiotherapy services: a pragmatic sequential mixed qualitative methods project

BACKGROUND

Improving access to radiotherapy services in low and middle-income countries (LMICs) is challenging. Many LMICs' radiotherapy initiatives fail because of multi-faceted barriers leading to significant wastage of scarce resources. Supporting LMICs to self-assess their readiness for establishing radiotherapy services will help to improve cancer outcomes by ensuring safe, effective and sustainable evidenced-based cancer care. The aim of the study was to develop practical guidance for LMICs on self-assessing their readiness to establish safe and sustainable radiotherapy services.

METHODS

The Access to Radiotherapy for Cancer treatment (ARC) Project was a pragmatic sequential mixed qualitative methods design underpinned by the World Health Organisation's 'Innovative Care for Chronic Conditions Framework' and 'Health System Building Blocks Framework for Action' conceptual frameworks. This paper reports on the process of overall data integration and meta-inference from previously published components comprising a systematic review and two-part qualitative study (semi-structured interviews and a participant validation process). The meta-inferences enabled a series of radiotherapy readiness self-assessment requirements to be generated, formalised as a REadiness SElf-Assessment (RESEA) Guide' for use by LMICs.

FINDINGS

The meta-inferences identified a large number of factors that acted as facilitators and/or barriers, depending on the situation, which include: awareness and advocacy; political leadership; epidemiological data; financial resources; basic physical infrastructure; radiation safety legislative and regulatory framework; project management; and radiotherapy workforce training and education. 'Commitment', 'cooperation', 'capacity' and 'catalyst' were identified as the key domains enabling development of radiotherapy services. Across these four domains, the RESEA Guide included 37 requirements and 120 readiness questions that LMICs need to consider and answer as part of establishing a new radiotherapy service.

CONCLUSIONS

The RESEA Guide provides a new resource for LMICs to self-assess their capacity to establish safe and sustainable radiotherapy services. Future evaluation of the acceptability and feasibility of the RESEA Guide is needed to inform its validity. Further work, including field study, is needed to inform further refinements. Exploratory and confirmatory factor analyses are required to reduce the data set and test the fit of the four-factor structure (commitment, cooperation, capacity and catalyst) found in the current study.

Development and testing of a guideline document to provide essential information for patient decision making regarding cancer clinical trials

OBJECTIVE

To develop and test a guideline document to advise the content of a summarised patient information form (SPIF) regarding cancer clinical trials.

METHODS

A two-phase study was undertaken to inform the development of the guideline document. In phase 1, 15 statements drawn from an international Delphi study and participant commentary were used to draft content for the guideline document. In phase 2, Delphi participants were invited to contribute to a five-step process via an online survey, to feedback on the guideline document, including the process for guideline formulation, testing application, revision, utility and clarity assessment, and completion.

RESULTS

Over 73% of respondents to the online survey agreed that a sample SPIF generated by the draft guideline could support patient decision making. After the draft guideline revision, the researcher and four health professionals used the guideline to independently create a SPIF. The Flesch-Kincaid reading ease scores of the sample SPIFs were between 61.3 and 66.5, with reading levels between 7.8 and 8.8, indicating that the guideline document can assist health professionals with the generation of an understandable SPIF. The reference group members provided positive feedback on the guideline document, and an expert on plain language in healthcare information proofread the guideline document.

CONCLUSION

The approach used in the study ensured the potential of the guideline document developed to enable generation of SPIFs that provide patients considering participation in a cancer clinical trial with essential and understandable information to support their decision making.

Developing a readiness self-assessment tool for low- and middle-income countries establishing new radiotherapy services: A participant validation study

PURPOSE

Assessing low-and middle-income countries' (LMICs') readiness to establish new radiotherapy services is an important but empirically understudied concept. The purpose of this study is to develop and confirm a core set of readiness requirements and criteria that can be used to gauge LMICs preparedness to establish radiotherapy services.

METHODS

Based on a systematic review and semi-structured expert interviews, a pool of requirements and criteria were generated. To confirm or disconfirm these items, we adopted a synthesised member checking process, also known as participant validation. A purposive sampling strategy was used to recruit radiotherapy experts. Items were sent via email. Each item was reviewed by participants. Qualitative comments were analysed thematically.

FINDINGS

Seven of the 17 experts who participated in an earlier semi-structured interview contributed to this participant validation study. The final version of the readiness self-assessment tool for LMICs establishing new radiotherapy services contains 37 requirements mapped into four readiness domains, grouped under the following categories: commitment; cooperation; capacity; and catalyst. Among 23 criteria for commitment domain, participants reviewed 22 as relevant for inclusion. The cooperation requirements considered important, included: "strategic planning team", "stakeholder involvement" and a "technical assistance plan". Capacity requirements, which were endorsed included: "responsible project manager"; "availability of radiotherapy expertise"; and "training for initial core staff". Participants' feedbacks supported the inclusion of all the requirements and criteria related to catalyst.

CONCLUSION

The readiness self-assessment tool is a promising planning and evaluation tool for use by stakeholders interested in expanding access to radiotherapy services in LMICs.

Experiences of barriers and facilitators to establishing and sustaining radiotherapy services in low- and middle-income countries: A qualitative study

AIMS

The factors contributing to the establishment of high-quality radiotherapy services in low- and middle-income countries (LMICs) are poorly understood. The aim was to identify and describe barriers and facilitators to establishing and sustaining high-quality and accessible radiotherapy services in LMICs based on the experience of successful and unsuccessful attempts.

METHODS

An exploratory-descriptive qualitative study using semistructured telephone interviews was undertaken. Purposive and snowball sampling techniques were used to recruit participants. The World Health Organization Innovative Care for Chronic Conditions Framework informed the interview guide. A constant comparative data analysis approach was adopted.

FINDINGS

Seventeen participants were interviewed. Ten were working permanently in nine LMICs and seven were permanently employed in four high-income countries. Three themes were developed: committing to a vision of improving cancer care; making it happen and sustaining a safe service; and leveraging off radiotherapy to strengthen integrated cancer care. Identified barriers included lack of political leadership continuity, lack of a coordinated advocacy effort, non-Member State of the IAEA, lack of reliable epidemiological data, lack of a comprehensive budget and lack of local expertise. Facilitators identified included strong political support, vision champion, availability of a regulator, costed cancer control plan, diversified sources of funding, responsible project manager, adoption of evidence-based practice, strategic partnerships, motivation to provide patient-centered care, and availability of supportive technology.

CONCLUSIONS

Assessing the level of readiness to establish and sustain a radiotherapy service is highly recommended. Future research is recommended to develop a readiness assessment tool for radiotherapy services implementation at LMICs.

Understanding rural caregivers' experiences of cancer care when accessing metropolitan cancer services: a qualitative study

OBJECTIVE

To explore the experiences of cancer caregivers who live in rural Australia and travel to a metropolitan cancer health service to access cancer treatment.

DESIGN

A qualitative study using semistructured, audio-recorded interviews conducted between December 2017 and July 2018 with caregivers and social workers. Thematic analysis using interpretative descriptive techniques performed on textual interview data within a critical realist paradigm to develop understanding of rural caregivers' lived experiences.

SETTING

Participants were from rural areas attending a metropolitan cancer centre in Australia and social workers.

PARTICIPANTS

21 caregivers (16 female) of people with cancer living in rural Australia within a minimum distance of 100 km from the metropolitan cancer centre where they access treatment, and five social workers employed at a metropolitan cancer service with experience of working with rural patients and caregivers.

RESULTS

Thematic analysis developed two overarching themes: theme 1: caregiving in the rural setting describes the unique circumstance in which caregiving for a person with cancer takes place in the rural setting at considerable distance from the cancer service where the person receives treatment. This is explored in three categories: 'Rural community and culture', 'Life adjustments' and 'Available supports'. Theme 2: accessing metropolitan cancer services captures the multiplicity of tasks and challenges involved in organising and coordinating the journey to access cancer treatment in a metropolitan hospital, which is presented in the following categories: 'Travel', 'Accommodation' and 'Health system navigation'.

CONCLUSIONS

Caregivers who live in rural areas face significant challenges when confronting geographic isolation between their rural home environment and the metropolitan setting, where the patient accessed cancer treatment. There is a need for healthcare services to identify this group to develop feasible and sustainable ways to provide interventions that have the best chance of assisting rural caregivers in supporting the patient while maintaining their own health and well-being.

Multidisciplinary home-based rehabilitation in inoperable lung cancer: a randomised controlled trial

BACKGROUND

Lung cancer is associated with poor health-related quality of life (HRQoL) and high symptom burden. This trial aimed to assess the efficacy of home-based rehabilitation versus usual care in inoperable lung cancer.

METHODS

A parallel-group, assessor-blinded, allocation-concealed, randomised controlled trial. Eligible participants were allocated (1:1) to usual care (UC) plus 8 weeks of aerobic and resistance exercise with behaviour change strategies and symptom support (intervention group (IG)) or UC alone. Assessments occurred at baseline, 9 weeks and 6 months. The primary outcome, change in between-group 6 min walk distance (6MWD), was analysed using intention-to-treat (ITT). Subsequent analyses involved modified ITT (mITT) and included participants with at least one follow-up outcome measure. Secondary outcomes included HRQoL and symptoms.

RESULTS

Ninety-two participants were recruited. Characteristics of participants (UC=47, IG=45): mean (SD) age 64 (12) years; men 55%; disease stage n (%) III=35 (38) and IV=48 (52); radical treatment 46%. There were no significant between-group differences for the 6MWD (n=92) at 9 weeks (p=0.308) or 6 months (p=0.979). The mITT analyses of 6MWD between-group differences were again non-significant (mean difference (95% CI): 9 weeks: -25.4 m (-64.0 to 13.3), p=0.198 and 6 months: 41.3 m (-26.7 to 109.4), p=0.232). Significant 6-month differences, favouring the IG, were found for HRQoL (Functional Assessment of Cancer Therapy-Lung: 13.0 (3.9 to 22.1), p=0.005) and symptom severity (MD Anderson Symptom Inventory-Lung Cancer: -2.2 (-3.6 to -0.9), p=0.001).

CONCLUSIONS

Home-based rehabilitation did not improve functional exercise capacity but there were improvements in patient-reported exploratory secondary outcomes measures observed at 6 months.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ACTRN12614001268639).

A longitudinal study of four unique trajectories of psychological distress in cancer survivors after completing potentially curative treatment

Background: Many survivors report short-term, transient psychological distress after cancer treatment. Some experience severe, worsening or persistent psychological morbidity which impairs functioning and warrants intervention. Using Bonanno's trajectories model, this study aimed to distinguish distress trajectories and to identify demographic, medical or psychosocial characteristics that differentiate those at risk of ongoing, clinically significant psychological distress. Methods: One-hundred and twenty-five cancer survivors of breast, prostate, colorectal or haematological cancers (response rate: 72%) completed measures of psychological distress (BSI-18), unmet needs (CASUN), social support (ESSI), coping styles (Mini-MAC), symptom prevalence (MSAS-SF) and benefit finding (PTGI) immediately after treatment and three and six months later. Distress and its predictors were investigated using linear mixed models. Groups based on Bonnano's trajectories were also compared on demographic, medical and psychosocial characteristics. Results: Changes in psychological distress over time were not statistically significant. Using BSI-18 clinical cut-off scores, most survivors (n = 65, 80%) were 'resilient', with stable, low distress levels. Almost one-tenth of survivors (n = 7, 9%) reported persistent, 'clinically significant' distress. Compared with the 'resilient' group, this 'chronic' group reported higher unmet needs, benefit finding, physical symptoms and poor coping styles, as well as lower social support immediately after treatment. They were also more likely to have a documented history of psychiatric illness. A 'recovered' group (n = 5, 6%) experienced high levels of distress that quickly returned to non-clinical levels and a delayed group (n = 4, 5%) reported initial low distress which worsened after treatment completion. Conclusions: Most survivors experience low distress (resilience) over time and may not require intense follow-up care. Screening for distress at the end of treatment may help to identify patients with more physical symptoms and unmet needs, less social support and higher use of maladaptive coping styles who are at risk of experiencing non-resilient trajectories of distress for further management of these symptoms.

The trials and tribulations of conducting an m-health pilot randomized controlled trial to improve oral cancer therapy adherence: recommendations for future multisite, non-drug clinical trials

OBJECTIVE

Integrating mobile phone-based health (m-health) interventions into healthcare systems is one solution to improve access to services for the growing number of patients with chronic illness. Practical challenges such as poor recruitment and inadequate resource allocation can hamper the assessment of such interventions with clinical trial methodology. This paper highlights the challenges encountered during a pilot randomized controlled trial of an m-health medication adherence intervention and offers recommendations for future multi-site, non-drug clinical trials.

RESULTS

Eighteen patients were recruited to the study; eight were randomly allocated to the intervention arm. Intervention participants responded to their daily medication-reminder text messages, indicating that medication had been taken or not, and nurses were able to organize their calls around their workload. The trial closed prematurely primarily due to inadequate numbers of eligible patients; however, other potentially resolvable feasibility issues were identified. These included lack of infrastructure at study sites, poor screening data acquisition and management processes, and inexperience in conducting supportive care trials at participating sites. M-health intervention trials are designed to inform implementation of best supportive care practice. Adequate skills and infrastructure are research prerequisites that require careful consideration and sufficient investment for the successful execution of multi-site supportive care trials. Trial registration Australian and New Zealand Clinical Trials Register: ACTRN12612000635864.

Assessing the cost-effectiveness of RT Prepare: A radiation therapist-delivered intervention for reducing psychological distress prior to radiotherapy

OBJECTIVE

To determine the cost-effectiveness of RT Prepare in reducing breast cancer patients' psychological distress before treatment, compared with usual care.

METHODS

RT Prepare, an intervention involving patient education and support consultations with a radiation therapist (RT), was implemented at three Australian sites (Australian New Zealand Clinical Trials Registration: ACTRN12611001000998). The primary outcome was change in psychological distress using the Hospital Anxiety and Depression Scale (HADS); secondary outcomes were changes in quality of life (QoL) and additional health service use. Costs (2015 $AU) included consultation time and training delivery. Between-group comparisons of HADS and QoL used generalised linear mixed models, and comparisons of health service use used negative binomial regression. Incremental cost-effectiveness ratios (ICERs) indicated mean costs per 1-point decrease in HADS score. Sensitivity analyses explored variation in facility size and uncertainty in intervention effectiveness.

RESULTS

Among 218 controls and 189 intervention participants, the intervention significantly lowered HADS scores at treatment commencement (adjusted mean difference 1.06 points). There was no significant effect on QoL or additional service use. Mean intervention costs were AU$171 per participant (US$130, €119) mostly related to RT training (approximately AU$142 (US$108, €99). An ICER of $158 (US$120, €110) was estimated. Cost-effectiveness improved in a sensitivity analysis representing a large facility with higher patient numbers.

CONCLUSION

This study provides new data on the cost-effectiveness of an RT-delivered intervention to reduce psychological distress prior to treatment, which will be useful to inform delivery of similar services. As most costs were upfront, cost-effectiveness would likely improve if implemented as standard care.

Predicting Family Caregiver Psychosocial Functioning in Palliative Care

Background

Health professionals are expected to support family caregivers of patients requiring palliative care. However, there is a dearth of empirical evidence to help clinicians identify caregivers who might be at risk of poor psychosocial functioning.

Purpose

This secondary analysis of baseline data from a larger study sought to determine if it was possible to predict the psychosocial functioning of family caregivers who were supporting a relative with advanced incurable cancer.

Method

Data from 35 primary family caregivers obtained at the start of home-based palliative care services and five weeks later was used in the analysis. Instruments to measure caregiver preparedness, competence, mastery, social support, anxiety, and self-efficacy were used.

Results

Cluster and logistic analyses revealed that self-reported “anxiety” and “competence” subscale total scores at time of commencement of home-based palliative care services were associated with caregivers at risk of lower levels of psychosocial functioning five weeks later.

Conclusions

This study suggests that it may be possible to identify family caregivers who are at risk for poorer psychosocial functioning. However, replication in a larger sample is required before this screening approach can be recommended for clinical use.

A systematic review of cancer caregiver interventions: Appraising the potential for implementation of evidence into practice

Objective

nformal caregivers provide substantial support for people living with cancer. Previous systematic reviews report on the efficacy of cancer caregiver interventions but not their potential to be implemented. The aim of this systematic review was to explore the potential for cancer caregiver interventions to be implemented into practice.

Methods

We searched three electronic databases to identify cancer caregiver interventions on 5 January 2018. We operationalised six implementation outcomes (acceptability, adoption, appropriateness, feasibility, fidelity, and costs) into a tool to guide data extraction.

Results

The search yielded 33 papers (27 papers from electronic databases and six papers from other sources) reporting on 26 studies that met review criteria. Fewer than half the studies (46%) contained evidence about the acceptability of interventions from caregivers' perspectives; only two studies (8%) included interventions developed with input from caregivers. Two studies (8%) addressed potential adoption of interventions, and no studies discussed intentions, agreement, or action to implement interventions into practice. All studies reported on intervention appropriateness by providing a rationale for the interventions. For feasibility, on average less than one‐third of caregivers who were eligible to be involved consented to participate. On fidelity, whether interventions were conducted as intended was reported in 62% of studies. Cost data were reported in terms of intervention delivery, requiring a median time commitment of staff of 180 minutes to be delivered.

Conclusions

Caregiver intervention studies lack components of study design and reporting that could bridge the gap between research and practice. There is enormous potential for improvements in cancer caregiver intervention study design to plan for future implementation.

Identifying priorities for cancer caregiver interventions: protocol for a three-round modified Delphi study

INTRODUCTION

Cancer is often considered a chronic disease, and most people with cancer have a caregiver, often a family member or friend who provides a significant amount of care during the illness trajectory. Caregivers are frequently in need of support, and a range of interventions have been trialled to improve outcomes. Consensus for optimal ways to support caregivers is not known. The aim of this protocol paper is to describe procedures for a modified Delphi study to explore expert consensus about important factors when developing caregiver interventions.

METHODS AND ANALYSIS

Online modified Delphi methodology will be used to establish consensus for important caregiver intervention factors incorporating the Patient problem, Intervention, Comparison and Outcome framework. Round 1 will comprise a free-text questionnaire and invite the panel to contribute factors they deem important in the development and evaluation of caregiver interventions. Round 2 is designed to determine preliminary consensus of the importance of factors generated in round 1. The panel will be asked to rate each factor using a 4-point Likert-type scale. The option for panellists to state reasoning for their rating will be provided. Descriptive statistics (median scores and IQR) will be calculated to determine each item's relative importance. Levels of consensus will be assessed based on a predefined consensus rating matrix. In round 3, factors will be recirculated including aggregate group responses (statistics and comment summaries) and panellists' own round 2 scores. Panellists will be invited to reconsider their judgements and resubmit ratings using the same rating system as in round 2. This will result in priority lists based on the panel's total rating scores.

ETHICS AND DISSEMINATION

Ethics for this study has been gained from the Deakin University Human Ethics Advisory Group. It is anticipated that the results will be published in peer-reviewed journals and presented in a variety of forums.

Defining success factors to describe coordinated care in cancer

Providing coordinated care remains a challenge for cancer services globally. There is a lack of consensus in the literature about what constitutes successful coordinated care. This study aimed to define and prioritize a set of consensus-driven success factors that can lead to coordinated care. A mixed-methods approach was used that included literature review, a broad call for submissions from relevant stakeholders, and a priority-setting process based on a modified nominal group technique. Thirty articles that related to success factors in coordinated care were identified in the literature. Twenty submissions were received from a broad range of stakeholders. From these sources, a set of 20 success factors was derived. Seventy stakeholders attended a series of workshops across New South Wales, Australia, to review and prioritize these 20 success factors against significance and measurability. Clear consensus was reached on prioritizing two success factors linked to improving coordinated care from first presentation to diagnosis and ensuring that patients are routinely screened for physical and supportive care needs. Other highly ranked factors included the need for a comprehensive care plan and the identification of patients at higher risk for disjointed care. This study defines and prioritizes a set of success factors related to coordinated care in cancer. These success factors will be used to guide the development of interventions that target improving coordinated care as well as supporting the development of new funding models based on performance indicators derived from these factors.

Identifying essential information to support patient decision-making regarding participation in cancer clinical trials: A Delphi study

PURPOSES

This research set out to contribute to ongoing efforts to improve the quality of informed consent information provided to patients by specifically focusing on establishing consensus with regard to essential information to enhance the informed consent process.

DESIGN AND METHODS

A Delphi consensus method was used to conduct three rounds of online surveys. Five groups of experts directly or indirectly involved in the informed consent process were invited to participate: patients, family members/friends, physicians, other health professionals and other key informants, including ethicists, contract research staff and pharmaceutical company staff.

FINDINGS

Of 156 eligible participants, 101 participants (64.7%) completed all three rounds. In round 1, 994 information items were reported and generated into 74 statements. These were grouped under eight headings essential to the informed consent process. In rounds 2 and 3, the list was reduced to 15 statements representing consensus on essential information to be included in a summarised patient information document to support decision-making regarding trial participation. Risks and discomforts, participation requirements and trial governance were identified as important considerations.

CONCLUSIONS

The 15 essential statements identified in this study could be used as components of a summarised information sheet given to potential cancer clinical trial participants, as an adjunct to the informed consent process. A robust evaluation of the impact of these statements on the quality of the informed consent process is needed.

Improving Health Outcomes for People With Cancer in Rural and Regional Areas by Embedding Evidence-Based Smoking-Cessation Strategies Into Usual Care: A Study Protocol

Background: Smoking following a diagnosis of cancer is a powerful clinical risk indicator, with known poorer health outcomes and associated health care costs. In Australia, smoking rates are higher in rural and regional areas. There are established and effective interventions to promote smoking cessation after a diagnosis of cancer yet these are not in routine practice. Aim: This protocol paper reports on a study that aims to embed evidence-based smoking cessation strategies for people with cancer who are current smokers into routine care, resulting in in system wide improvements, an implemented program and model for further dissemination. Methods: Across three rural/regional sites, and with partners Quit Victoria and Western Alliance, this study employs a variety of methodologies to embed smoking cessation support to improve outcomes for people with cancer who currently smoke. Specifically, the project will embed a system of responsibilities and training in rural and regional health services to routinely engage people with cancer who smoke in support services. The program will: · Promote routine delivery of smoking cessation care by trained oncology staff (oncologists/nurses/ allied health) · Establish referral pathways to Quitline · Correspond with general practitioners, to: i) outline the benefits of quitting in this context, ii) promote access to nicotine replacement therapy and iii) support quitting in the community. · Improve routine recording of smoking status and documentation of provision of brief intervention (personalised advice given, resources provided) and outcomes. Participants: are oncology staff and general practitioners across three health services: Ballarat Health Service, East Grampians Health Service (Ararat), Wimmera Health Care Group (Horsham), all located in Victoria, Australia. Data collection will occur across four sources: 1) Oncology staff: qualitative and quantitative data collection understanding confidence and views on provision on cessation advice; 2) Monitoring Quitline calls, 3) Interview with local general practitioners and 4) Medical record reviews to explore frequency of recording of smoking status. Data will be collected pre/postintervention. Results: The project is underway with the intervention manuals in development. The project is due for completion in 2020. Conclusion: This project takes a health services approach to integration of smoking cessation support in routine care for people with cancer in rural and regional areas. This program of work has capacity to determine best approaches to integrate smoking cessation into routine care, resulting in reduced mortality and morbidity, improved effectiveness of anticancer treatments, and reduced health care costs; by establishing internationally relevant, embedded health care interventions.

Barriers and facilitators to implementation of cancer treatment and palliative care strategies in low- and middle-income countries: systematic review

OBJECTIVES

To appraise improvement strategies adopted by low- and middle-income countries to increase access to cancer treatments and palliative care; and identify the facilitators and barriers to implementation.

METHODS

A systematic review was conducted and reported in accordance with PRISMA statement. MEDLINE, CINAHL, and the Cochrane Library databases were searched. Bias was assessed using the Standards for Quality Improvement Reporting Excellence, and evidence graded using the Australian National Health and Medical Research Council system.

RESULTS

Of 3069 articles identified, 18 studied were included. These studies involved less than a tenth (n = 12, 8.6%) of all low- and middle-income countries. Most were case reports (58%), and the majority focused on palliative care (n = 11, 61%). Facilitators included: stakeholder engagement, financial support, supportive learning environment, and community networks. Barriers included: lack of human resources, financial constraints, and limited infrastructure.

CONCLUSIONS

There is limited evidence on sustainable strategies for increasing access to cancer treatments and palliative care in low- and middle-income countries. Future strategies should be externally evaluated and be tailored to address service delivery; workforce; information; medical products, vaccines, and technologies; financing; and leadership and governance.

Should women aged 70-74 be invited to participate in screening mammography? A report on two Australian community juries

OBJECTIVE

To elicit informed views from Australian women aged 70-74 regarding the acceptability of ceasing to invite women their age to participate in government-funded mammography screening (BreastScreen).

DESIGN

Two community juries held in 2017.

SETTING

Greater Sydney, a metropolis of 4.5 million people in New South Wales, Australia.

PARTICIPANTS

34 women aged 70-74 with no personal history of breast cancer, recruited by random digit dialling and previously randomly recruited list-based samples.

MAIN OUTCOMES AND MEASURES

Jury verdict and rationale in response to structured questions. We transcribed audio-recorded jury proceedings and identified central reasons for the jury's decision.

RESULTS

The women's average age was 71.5 years. Participants were of diverse sociocultural backgrounds, with the sample designed to include women of lower levels of educational attainment. Both juries concluded by majority verdict (16-2 and 10-6) that BreastScreen should continue to send invitations and promote screening to their age group. Reasons given for the majority position include: (1) sending the invitations shows that society still cares about older women, empowers them to access preventive health services and recognises increasing and varied life expectancy; (2) screening provides women with information that enables choice and (3) if experts cannot agree, the conservative approach is to maintain the status quo until the evidence is clear. Reasons for the minority position were the potential for harms through overdiagnosis and misallocation of scarce health resources.

CONCLUSIONS

Preventive programmes such as mammography screening are likely to have significant symbolic value once they are socially embedded. Arguments for programme de-implementation emphasising declining benefit because of limited life expectancy and the risks of overdiagnosis seem unlikely to resonate with healthy older women. In situations where there is no consensus among experts on the value of established screening programmes, people may strongly prefer receiving information about their health and having the opportunity make their own choices.

Mobile Health Intervention to Increase Oral Cancer Therapy Adherence in Patients With Chronic Myeloid Leukemia (The REMIND System): Clinical Feasibility and Acceptability Assessment

Background

Optimal dosing of oral tyrosine kinase inhibitor therapy is critical to treatment success and survival of patients with chronic myeloid leukemia (CML). Drug intolerance secondary to toxicities and nonadherence are significant factors in treatment failure.

Objective

The objective of this study was to develop and pilot-test the clinical feasibility and acceptability of a mobile health system (REMIND) to increase oral drug adherence and patient symptom self-management among people with CML (chronic phase).

Methods

A multifaceted intervention was iteratively developed using the intervention development framework by Schofield and Chambers, consisting of defining the patient problem and iteratively refining the intervention. The clinical feasibility and acceptability were examined via patient and intervention nurse interviews, which were audiotaped, transcribed, and deductively content analyzed.

Results

The intervention comprised 2 synergistically operating elements: (1) daily medication reminders and routine assessment of side effects with evidence-based self-care advice delivered in real time and (2) question prompt list (QPL) questions and routinely collected individual patient adherence and side effect profile data used to shape nurses’ consultations, which employed motivational interviewing to support adoption of self-management behaviors. A total of 4 consultations and daily alerts and advice were delivered over 10 weeks. In total, 58% (10/17) of patients and 2 nurses participated in the pilot study. Patients reported several benefits of the intervention: help in establishing medication routines, resolution of symptom uncertainty, increased awareness of self-care, and informed decision making. Nurses also endorsed the intervention: it assisted in establishing pill-taking routines and patients developing effective solutions to adherence challenges.

Conclusions

The REMIND system with nurse support was usable and acceptable to both patients and nurses. It has the potential to improve adherence and side-effect management and should be further evaluated.

Ending cervical cancer: A call to action

The outlook for elimination of the scourge of cervical cancer is bright, because we now have the tools to achieve this goal. In recent years human papillomavirus (HPV) vaccination in high-income countries has resulted in dramatic decreases in HPV infection and associated cervical disease. If all countries with a substantial burden of disease introduce the vaccine nationally, we can protect the vast majority of women and girls most at risk. For women who are beyond the vaccination target age, progress has been made in screening and treatment for cervical precancer, but we must accelerate this momentum to reduce incidence and mortality worldwide to the very low rates found in wealthier countries. Human and financial resources must be increased and directed to programs that follow best practices and reach all women, including the marginalized or disadvantaged. Seven key actions are recommended. Now is the time for action at national, regional, and global levels.

Benefits of home-based multidisciplinary exercise and supportive care in inoperable non-small cell lung cancer - protocol for a phase II randomised controlled trial

Background

Lung cancer is one of the most commonly diagnosed cancers, and is a leading cause of cancer mortality world-wide. Due to lack of early specific symptoms, the majority of patients present with advanced, inoperable disease and five-year relative survival across all stages of non-small cell lung cancer (NSCLC) is 14%. People with lung cancer also report higher levels of symptom distress than those with other forms of cancer. Several benefits for survival and patient reported outcomes are reported from physical activity and exercise in other tumour groups. We report the protocol for a study investigating the benefits of exercise, behaviour change and symptom self-management for patients with recently diagnosed, inoperable, NSCLC.

Methods

This multi-site, parallel-group, assessor-blinded randomised controlled trial, powered for superiority, aims to assess functional and patient-reported outcomes of a multi-disciplinary, home-based exercise and supportive care program for people commencing treatment. Ninety-two participants are being recruited from three tertiary-care hospitals in Melbourne, Australia. Following baseline testing, participants are randomised using concealed allocation, to receive either: a) 8 weeks of home-based exercise (comprising an individualised endurance and resistance exercise program and behaviour change coaching) and nurse-delivered symptom self-management intervention or b) usual care. The primary outcome is the between-group difference in the change in functional exercise capacity (six-minute walk distance) from baseline to post-program assessment. Secondary outcomes include: objective and self-reported physical activity levels, physical activity self-efficacy, behavioural regulation of motivation to exercise and resilience, muscle strength (quadriceps and grip), health-related quality of life, anxiety and depression and symptom interference.

Discussion

There is a lack of evidence regarding the benefit of exercise intervention for people with NSCLC, particularly in those with inoperable disease receiving treatment. This trial will contribute to evidence currently being generated in national and international trials by implementing and evaluating a home-based program including three components not yet combined in previous research, for people with inoperable NSCLC receiving active treatment and involving longer-term follow-up of outcomes. This trial is ongoing and currently recruiting.

Trial registration

This trial was prospectively registered on the Australian New Zealand Clinical Trials Registry (ACTRN12614001268639: (4/12/14).

Electronic supplementary material

The online version of this article (10.1186/s12885-017-3651-4) contains supplementary material, which is available to authorized users.

Cancer survival disparities worsening by socio-economic disadvantage over the last 3 decades in new South Wales, Australia

BACKGROUND

Public concerns are commonly expressed about widening health gaps. This cohort study examines variations and trends in cancer survival by socio-economic disadvantage, geographical remoteness and country of birth in an Australian population over a 30-year period.

METHODS

Data for cases diagnosed in New South Wales (NSW) in 1980-2008 (n = 651,245) were extracted from the population-based NSW Cancer Registry. Competing risk regression models, using the Fine & Gray method, were used for comparative analyses to estimate sub-hazard ratios (SHR) with 95% confidence intervals (CI) among people diagnosed with cancer.

RESULTS

Increased risk of cancer death was associated with living in the most socio-economically disadvantaged areas compared with the least disadvantaged areas (SHR 1.15, 95% CI 1.13-1.17), and in outer regional/remote areas compared with major cities (SHR 1.05, 95% CI 1.03-1.06). People born outside Australia had a similar or lower risk of cancer death than Australian-born (SHR 0.99, 95% CI 0.98-1.01 and SHR 0.91, 95% CI 0.90-0.92 for people born in other English and non-English speaking countries, respectively). An increasing comparative risk of cancer death was observed over time when comparing the most with the least socio-economically disadvantaged areas (SHR 1.07, 95% CI 1.04-1.10 for 1980-1989; SHR 1.14, 95% CI 1.12-1.17 for 1990-1999; and SHR 1.24, 95% CI 1.21-1.27 for 2000-2008; p < 0.001 for interaction between disadvantage quintile and year of diagnosis).

CONCLUSIONS

There is a widening gap in comparative risk of cancer death by level of socio-economic disadvantage that warrants a policy response and further examination of reasons behind these disparities.

After accounting for competing causes of death and more advanced stage, do Aboriginal and Torres Strait Islander peoples with cancer still have worse survival? A population-based cohort study in New South Wales

Background

Aboriginal and Torres Strait Islander peoples in Australia have been found to have poorer cancer survival than non-Aboriginal people. However, use of conventional relative survival analyses is limited due to a lack of life tables. This cohort study examined whether poorer survival persist after accounting for competing risks of death from other causes and disparities in cancer stage at diagnosis, for all cancers collectively and by cancer site.

Methods

People diagnosed in 2000–2008 were extracted from the population-based New South Wales Cancer Registry. Aboriginal status was multiply imputed for people with missing information (12.9%). Logistic regression models were used to compute odds ratios (ORs) with 95% confidence intervals (CIs) for ‘advanced stage’ at diagnosis (separately for distant and distant/regional stage). Survival was examined using competing risk regression to compute subhazard ratios (SHRs) with 95%CIs.

Results

Of the 301,356 cases, 2517 (0.84%) identified as Aboriginal (0.94% after imputation). After adjusting for age, sex, year of diagnosis, socio-economic status, remoteness, and cancer site Aboriginal peoples were more likely to be diagnosed with distant (OR 1.30, 95%CI 1.17–1.44) or distant/regional stage (OR 1.29, 95%CI 1.18–1.40) for all cancers collectively. This applied to cancers of the female breast, uterus, prostate, kidney, others (those not included in other categories) and cervix (when analyses were restricted to cases with known stages/known Aboriginal status). Aboriginal peoples had a higher hazard of death than non-Aboriginal people after accounting for competing risks from other causes of death, socio-demographic factors, stage and cancer site (SHR 1.40, 95%CI 1.31–1.50 for all cancers collectively). Consistent results applied to colorectal, lung, breast, prostate and other cancers.

Conclusions

Aboriginal peoples with cancer have an elevated hazard of cancer death compared with non-Aboriginal people, after accounting for more advanced stage and competing causes of death. Further research is needed to determine reasons, including any contribution of co-morbidity, lifestyle factors and differentials in service access to help explain disparities.

Self-guided interventions for managing psychological distress in people with cancer - A systematic review

OBJECTIVE

People with cancer can experience psychological distress but do not always desire, or engage with, professional support to assist with managing distress. Interventions that are self-directed or guided by patients may hold promise as they allow patients to engage with interventions as they need. The objective of this review is to describe and appraise the evidence for effectiveness of self-guided interventions that aim to manage psychological distress in people with cancer.

METHODS

A systematic search of Medline, PsychInfo and CINAHL identified 15 relevant papers, reporting on 14 studies.

RESULTS

Of the interventions, three studies comprised hard-copy workbooks, six studies used resource packs, four were online resources and one was a brief multimedia resource. One study was adequately powered and demonstrated a positive effect. Almost all interventions required some level of facilitation. Distressed participants may benefit more from interventions.

CONCLUSION

Self-guided interventions represent a potentially efficient way of delivering support for people affected by cancer, however evidence supporting them is lacking.

PRACTICE IMPLICATIONS

There is a need to generate evidence to understand the impact of self-guided interventions for: i) the ideal delivery point in the disease trajectory, ii) patient groups, iii) intervention content and iv) type and mode of delivery.

Pancreatectomy is underused in NSW regions with low institutional surgical volumes: a population data linkage study

OBJECTIVE

To examine differences in the proportions of people diagnosed with pancreatic cancer who underwent pancreatectomy, post-operative outcomes and 5-year survival in different New South Wales administrative health regions of residence.

DESIGN, SETTING AND PARTICIPANTS

Retrospective analysis of NSW data on pancreatic cancer incidence and surgery, 2005-2013.

MAIN OUTCOME MEASURES

The proportion of newly diagnosed patients with pancreatic cancer who were resected in each region; 90-day post-operative mortality; one-year post-operative survival; 5-year post-diagnosis survival.

RESULTS

14% of people diagnosed with pancreatic cancer during 2010-2013 (431 of 3064) underwent pancreatectomy, an average of 108 resections per year. After adjusting for age, sex and comorbidities, the proportion that underwent resection varied significantly between regions, ranging between 8% and 21% (P<0.001). Higher resection rates were not associated with higher post-operative 90-day mortality or lower one-year survival (unadjusted and risk-adjusted analyses). Higher resection rates were associated with higher 5-year post-diagnosis survival: the mean survival in regions with resection rates below 10% was 3.4%, compared with 7.2% in regions with rates greater than 15% (unadjusted and adjusted survival analyses; P<0.001). There was a positive association between regional resection rate and the pancreatectomy volume of hospitals during 2005-2009. An additional 32 people would be resected annually if resection rates in low rate regions were increased to the 80th percentile regional resection rate (18%).

CONCLUSION

There is significant geographic variation in the proportion of people with pancreatic cancer undergoing pancreatectomy, and the 5-year survival rate is higher in regions where this proportion is higher.