Transforming melanoma prevention: The development, validation and efficacy of model-generated risk predictions in Australian primary care

Personalised model generated risk predictions that incorporate several risk factors may motivate people to increase sun protection. The aim of the thesis is to evaluate and build the quality of the evidence for melanoma risk prediction models, contribute to knowledge of melanoma risk factors for inclusion in risk prediction models, and evaluate their effectiveness as preventive tools inclinical practice. Chapter 1 presents an overview of the epidemiology and role of melanoma risk prediction models in prevention. Chapter 2 presents the results of a systematic review of melanoma risk prediction models. The systematic review identified 28 melanoma risk prediction models. However, there was limited reporting of model development and performance measures, and few studies were externally validated or prospectively evaluated in clinical settings. Chapter 3 evaluates occupational sun exposure and melanoma risk to improve understanding of whether this risk factor should be considered for inclusion in risk prediction models by use of two population based case control studies. There was no association between occupational sun exposure and melanoma risk overall or according to anatomical site. Chapters 4 and 5 presents the development and validation of two melanoma risk prediction models, one using self assessed risk factors and the other using clinicallyassessed risk factors. Chapter 6 presents the results of a pragmatic randomised controlled trial, in which 272 Australian general practice patients were randomly allocated to receive (1) real time personalised model generated risk predictions based on self assessed risk factors and tailored prevention advice, or (2) generic prevention advice. There were no statistically significant differences between intervention and control patients in sun protection practices (p=0.13). However average risk patients in the intervention group appeared to show greater sun protection at 6 weeks (mean difference=0.23, on a scale of 1 to 5; 95% confidence interval: 0.01 to 0.45; p=0.04). This thesis adds high quality evidence relevant to the prevention of me lanoma from the development and validation of model generated risk predictions to their implementation and efficacy in clinical practice and is likely to have an impact on preventative care in Australia and internationally

Demystifying human research ethics committee applications

Background The National Health and Medical Research Council’s National Statement on Ethical Conduct in Human Research and updated Guidelines for Ethical Conduct in Aboriginal and Torres Strait Islander Health Research provide guidance for primary care researchers. Objective This paper describes a step-by-step approach to ethics applications for research projects in primary care for new or inexperienced researchers, or those new to primary care research. Discussion Domains that may enhance ethics applications include increased consumer involvement; comprehensive literature reviews; evidence of researcher training in ethical research and clinical trials; the use of online platforms for participant information, consent processes and surveys; and consideration of the risks of genomic research or research in subpopulations. This paper discusses steps required when preparing ethics applications to ensure the community, clinicians and researchers are protected

Feasibility of a GP delivered skin cancer prevention intervention in Australia

Background: Despite years of public education, sun-related behaviours are difficult to change and a recent survey showed low levels of sun protection. In this study we evaluated the feasibility and acceptability of an opportunistic skin cancer prevention intervention in general practice. Methods: We used a controlled pre-and-post intervention design. Participants (n = 100) were recruited sequentially from patients attending two general practices in Sydney, Australia, from November to December 2010. Participants in the intervention practice (n = 50) received general practitioner delivered sun protection advice after completing a skin cancer risk assessment tool, and a sun protection pamphlet, in addition to routine care, at a single attendance. The skin cancer risk assessment tool provided three levels of risk. The general practitioner (GP) reinforced the level of risk and discussed sun protection. Participants in the control practice (n = 50) received routine care. We measured feasibility by patients’ and GPs’ participation in the intervention and time taken, and acceptability by intervention participants and GPs ratings of the intervention. We measured reported sun-related knowledge, attitudes and behaviour between the two groups at 1 and 13 months. Results: The intervention was found to be feasible within existing primary care team arrangements. Participation at baseline was 81% (108/134), and repeated participation was 88% (88/100) at 1 month and 70% (70/100) at 13 months. Participants and practitioners found the intervention acceptable. At 1 month, sun-related knowledge had increased in both patient groups, with a greater increase in the intervention group (adjusted mean difference 0.48, p = 0.034). There were no differences between groups in sun-related knowledge, attitudes and behaviour at 13 months. Conclusions: A brief opportunistic skin cancer prevention intervention in general practice is feasible and acceptable. Further research in this setting with a more intensive intervention would be justified

Occupational sun exposure and risk of melanoma according to anatomical site

Although sunburn and intermittent sun exposures are associated with increased melanoma risk, most studies have found null or inverse associations between occupational (more continuous pattern) sun exposure and melanoma risk. The association of melanoma with occupational sun exposure may differ according to anatomical site, with some studies finding a positive association with melanoma on the head and neck. We examined the association between occupational sun exposure (self-reported weekday sun exposure) and melanoma risk according to anatomical site, using data from two multicentre population-based case-control studies: the Australian Melanoma Family Study (588 cases, 472 controls) and the Genes, Environment and Melanoma study (GEM; 1079 cases, 2,181 controls). Unconditional logistic regression was used to estimate odds ratios (OR) and their 95% confidence intervals, adjusting for potential confounders. Occupational sun exposure was not positively associated with melanoma risk overall or at different body sites in both studies. The GEM study found inverse associations between occupational sun exposure and melanoma on the head and neck [OR for highest vs. lowest quartile: 0.56, 95% confidence intervals (CI) 0.36-0.86, ptrend 0.02], and between the proportion of total sun exposure occurring on weekdays and melanoma on the upper limbs (OR for highest vs. lowest quartile: 0.66, 95% CI 0.42-1.02, ptrend 0.03). Our results suggest that occupational sun exposure does not increase risk of melanoma, even of melanomas situated on the head and neck. This finding seemed not to be due to negative confounding of occupational sun exposure by weekend sun

“We're trained to trust our patients”: a qualitative study on the general practitioners' trust in patients for colorectal cancer shared care

BackgroundIn a therapeutic partnership, physicians rely on patients to describe their health conditions, join in shared decision-making, and engage with supported self-management activities. In shared care, the patient, primary care, and specialist services partner together using agreed processes and outputs for the patient to be placed at the centre of their care. However, few empirical studies have explored physicians’ trust in patients and its implications for shared care models.AimTo explore trust in patients amongst general practitioners (GPs), and the impacts of trust on GPs’ willingness to engage in new models of care, such as colorectal cancer shared care.MethodsGP participants were recruited through professional networks for semi-structured interviews. Transcripts were integrity checked, coded inductively, and themes developed iteratively.ResultsTwenty-five interviews were analysed. Some GPs view trust as a responsibility of the physician and have a high propensity for trusting patients. For other GPs, trust in patients is developed over successive consultations based on patient characteristics such as honesty, reliability, and proactivity in self-care. GPs were more willing to engage in colorectal cancer shared care with patients with whom they have a developed, trusting relationship.ConclusionsTrust plays a significant role in the patient’s access to shared care. The implementation of shared care should consider the relational dynamics between the patient and health care providers

GP attitudes to and expectations for providing personal genomic risk information to the public: a qualitative study

Background: As part of a pilot randomised controlled trial examining the impact of personal melanoma genomic risk information on behavioural and psychosocial outcomes, GPs were sent a booklet containing their patient’s genomic risk of melanoma. Aim: Using this booklet as an example of genomic risk information that might be offered on a population-level in the future, this study explored GP attitudes towards communicating genomic risk information and resources needed to support this process. Design & setting: Semi-structured interviews were conducted with 22 Australian GPs. Method: The interviews were recorded and transcribed, and data were analysed thematically. Results: GPs in this sample believed that communicating genomic risk may become a responsibility within primary care and they recommended a shared decisionmaking approach to guide the testing process. Factors were identified that may influence how and when GPs communicate genomic risk information. GPs view genomics-based risk as one of many disease risk factors and feel that this type of information could be applied in practice in the context of overall risk assessment for diseases for which prevention and early detection strategies are available. They believe it is important to ensure that patients understand their genomic risk and do not experience long-term adverse psychological responses. GPs desire clinical practice guidelines that specify recommendations for genomic risk assessment and patient management, point-of-care resources, and risk prediction tools that include genomic and traditional risk factors. Conclusion: These findings will inform the development of resources for preparing GPs to manage and implement genomic risk information in practice