Evaluation of directional vacuum-assisted breast biopsy: Report for the National Breast Cancer Centre final report, CHERE Project Report No 21

This project was commissioned by the National Breast Cancer Centre (NBCC). The objectives of the project, as set out in the call for expressions of interest, were to determine: 1. The costs associated with the introduction and use of directional vacuum-assisted breast biopsy(DVA breast biopsy) in Australia; and 2. Whether directional vacuum-assisted breast biopsy used for diagnostic purposes is cost-effectivein Australia when compared to core biopsy. The motivation for commissioning the project was an assessment of directional vacuum-assisted breast biopsy conducted by the Medical Services Advisory Committee (MSAC) which concluded that the procedure is safe and more effective than core biopsy. Although a cost-effectiveness analysis was not conducted as part of the MSAC study, MSAC recommended that the costs associated with the procedure be investigated and that, pending a review of costs, the procedure receive interim Medicare funding at a higher level than was previously available. For the project reported here, data was required to be collected from both public and private sectors on the cost of introducing and using DVA breast biopsy and a cost-effectiveness analysis (CEA) conducted on the introduction and use of DVA breast biopsy with and without a prone table. The research question for the CEA was What is the impact on costs and number of open biopsies performed of using DVA breast biopsy compared to core biopsy for micro-calcification lesions? It is important to note that this question specifies both the outcome the CEA (change in the number of core biopsies performed) and that the investigation was to be confined to micro-calcification lesions only. An expert multidisciplinary working group was assembled to oversee the project. Following collection of data an interim report was produced for the working group. As DVABB is a relatively new technology in Australia the interim report indicated that the current number of sites performing DVABB and the level of experience of users was insufficient to provide meaningful data to achieve the project aims. On the advice of the working group it was agreed to suspend the project at this juncture. The NBCC will consider repeating the survey in the future.Breast cancer, diagnostics, breast biopsy, Australia

Cancer Care Coordinators: Realising the Potential for Improving the Patient Journey

A person diagnosed with cancer can receive multiple treatments in a variety of different health care settings over extended periods of time1. During this time, they come into contact with multiple health care providers. For example, one recent UK study reported that cancer patients with a diagnosis of less than one year had met 28 doctors on average since their diagnosis2. Add to this the many other health professionals with whom the patient will come into contact during their illness and the complex maze that can characterise the patient’s cancer journey is obvious. The Optimising Cancer Care in Australia report3 published in 2003 by the peak cancer organisations in Australia concluded that there are many places for the person with cancer to get lost in the system, causing unnecessary morbidity and undue distress. The lack of an integrated care system for people with cancer was identified as a major failing of today’s health system3. A number of states in Australia have moved to appoint cancer care coordinators as a strategy to address such problems. In Queensland, cancer coordination positions have been established in a number of Health Service Districts in the Southern and Central Zone of the State, initially to scope patterns of care, referral pathways and to define a cancer coordination model for their regions that is consistent across the state, but able to meet the local needs of the population. To support its Cancer Clinical Service Framework, the NSW Health Department plans to recruit up to 50 cancer nurse coordinators. Cancer nurse coordinators in NSW will work through Lead Clinicians and Directors of Area Cancer Services to support oncology team meetings, develop care pathways and protocols, and provide a direct source of contact for patients and primary care physicians accessing cancer services4. In Victoria, a number of program coordinators and regional nurse coordinators have been introduced as part of the breast services enhancement program. Individual institutions have also established nurse coordinator roles for specific tumour streams. The cancer care coordinator role is a rapidly emerging one with a mandate to achieve some potentially far-reaching reforms to systems of care. To ensure these developments realise their potential, it is timely to consider the most effective ways to design and implement models of care coordination thatachieve the improvements being sought for the Australian cancer care system

The 2003 Australian Breast Health Survey: survey design and preliminary results

<p>Abstract</p> <p>Background</p> <p>The Breast Health Surveys, conducted by the National Breast Cancer Centre (NBCC) in 1996 and 2003, are designed to gain insight into the knowledge, attitudes and behaviours of a nationally representative sample of Australian women on issues relevant to breast cancer. In this article, we focus on major aspects of the design and present results on respondents' knowledge about mammographic screening.</p> <p>Methods</p> <p>The 2003 BHS surveyed English-speaking Australian women aged 30–69 without a history of breast cancer using computer-assisted telephone interviewing. Questions covered the following themes: knowledge and perceptions about incidence, mortality and risk; knowledge and behaviour regarding early detection, symptoms and diagnosis; mammographic screening; treatment; and accessibility and availability of information and services. Respondents were selected using a complex sample design involving stratification. Sample weights against Australian population benchmarks were used in all statistical analyses. Means and proportions for the entire population and by age group and area of residence were calculated. Statistical tests were conducted using a level of significance of 0.01.</p> <p>Results</p> <p>Of the 3,144 respondents who consented to being interviewed, 138 (4.4%) had a previous diagnosis of breast cancer and were excluded leaving 3,006 completed interviews eligible for analysis. A majority of respondents (61.1%) reported ever having had a mammogram and 29.1% identified mammography as being the best way of finding breast cancer. A majority of women (85.9%) had heard of the BreastScreen Australia (BSA) program, the national mammographic screening program providing free biennial screening mammograms, with 94.5% believing that BSA attendance was available regardless of the presence or absence of symptoms. There have been substantial gains in women's knowledge about mammographic screening over the seven years between the two surveys.</p> <p>Conclusion</p> <p>The NBCC Breast Health Surveys provide a valuable picture of the knowledge of Australian women about a range of issues. The present analysis shows significant gains in knowledge and behaviours relating to mammographic screening, while identifying additional areas for targeted improvement, as in the need to better communicate with women about screening and diagnostic services. Further analysis of additional core topic areas (eg., incidence, mortality, risk and treatment) will provide equally noteworthy insight.</p

Early discontinuation of endocrine therapy for breast cancer: Who is at risk in clinical practice?

Purpose: Despite evidence supporting at least five years of endocrine therapy for early breast cancer, many women discontinue therapy early. We investigated the impact of initial therapy type and specific comorbidities on discontinuation of endocrine therapy in clinical practice. Methods We identified women in a population-based cohort with a diagnosis of early breast cancer and an incident dispensing of anastrozole, letrozole or tamoxifen from 2003-2008 (N = 1531). Pharmacy and health service data were used to determine therapy duration, treatment for pre-existing and post-initiation comorbidities (anxiety, depression, hot flashes, musculoskeletal pain, osteoporosis, vaginal atrophy), demographic and other clinical characteristics. Time to discontinuation of initial, and any, endocrine therapy was calculated. Cox regression determined the association of different characteristics on early discontinuation. Results Initial endocrine therapy continued for a median of 2.2 years and any endocrine therapy for 4.8 years. Cumulative probability of discontinuing any therapy was 17% after one year and 58% by five years. Initial tamoxifen, pre-existing musculoskeletal pain and newly-treated anxiety predicted shorter initial therapy but not discontinuation of any therapy. Early discontinuation of any therapy was associated with newly-treated hot flashes (HR = 2.1, 95%CI = 1.3-3.3), not undergoing chemotherapy (HR = 1.4, 95%CI = 1.1-1.8) and not undergoing mastectomy (HR = 1.5, 95%CI = 1.2-1.8). Conclusions Less than half of women completed five years of endocrine therapy. Women at greatest risk of stopping any therapy early were those with newly-treated hot flashes, no initial chemotherapy, or no initial mastectomy. This suboptimal use means that the reductions in recurrence demonstrated in clinical trials may not be realised in practice

Breast cancer survival by size and nodal status in Australia

This report provides relative survival data up to nine years after diagnosis for women diagnosed in Australia with breast cancer in 1997. There are breakdowns of survival proportions by size of cancer, nodal status, geographic region and socio-economic status

The perils of a vanishing cohort: A study of social comparisons by women with advanced ovarian cancer

Objective: To examine the role social comparisons play in the experience of ovarian cancer patients and to consider the implications this may have for provision of supportive care services for ovarian cancer patients. Methods: We conducted a longitudinal qualitative study of women with advanced ovarian cancer in Sydney, Australia. Semi-structured interviews were conducted with women with advanced ovarian cancer over a period of 2.5 years. Social comparisons made by 13 study participants in 33 interviews were extracted and analysed using coding categories based on social comparison theory. Results: Participants favoured downward contrasts and lateral comparisons and avoided downward identifications, upward contrasts and upward identifications. Participants expressed a preference for avoiding contact with ovarian cancer patients, for the company of “normal” others, for normalizing information and information that facilitated upward identifications. Conclusions: We suggest that social comparisons made by women with ovarian cancer are influenced by specific clinical factors associated with their diagnosis – in particular their status as a member of a “vanishing cohort” – and argue for further research examining the specific comparison needs and preferences of patients with advanced disease and types of cancer with poor prognoses. Practice implications: These findings raise questions about uniform approaches to the provision of cancer care and suggest that further research may be required to ensure that interventions are appropriately tailored to the supportive care needs of patients with different types and stages of disease. KEYWORDS Cancer; Oncology; Ovarian neoplasms; Social comparison theory; Social support; Self-help groupsNational Health & Medical Research Council Project Grant 40260

The psychological implications of breast cancer: A review of the literature ; Shattered motherhood: Young mothers living with breast cancer

The purpose of this paper is to provide a critical review regarding the psychological implications of breast cancer, with a particular focus on younger women. In general due to their life stage, it appears that younger women have more problems with psychological adjustment to breast cancer compared to their older counterparts. Specifically, younger women appear to be more psychologically vulnerable to greater disruption to their daily lives due to the untimely nature of a breast cancer diagnosis, and have greater unmet practical needs, such as childcare. Limitations of the research literature are explored with specific attention to sample characteristics. Suggestions for future research are discussed based on methodological and conceptual issues. It is indicated that long-term outcome studies are required to strengthen the knowledge already attained within this field. Breast cancer is the most common form of cancer diagnosed in females in Australia, and approximately 6% of women diagnosed with the disease are aged 40 or less. The experience of breast cancer in mothers of dependent children and the impact of breast cancer on mothers\u27 identities was the focus of this study. Eight women, with current or non-recurrent breast cancer, were interviewed using multiple case qualitative methodology from a feminist perspective as a theoretical framework. Six themes emerged from conducting the research and were centred on the participants\u27 identity as a mother: \u27breast cancer challenged my role as a mother\u27; \u27holding onto motherhood\u27; \u27mothering beyond the grave\u27; \u27I am a mother, not an object\u27; \u27help me to be a mother\u27 and; \u27I am a mother and I am still here\u27. The research found that the needs of mothers living with breast cancer, namely lack of instrumental and emotional support, are not being appropriately or adequately met. The study has implications for health care professionals regarding the psychological and social impact of breast cancer on mothers

Precision Imaging Ultrasound Technology - Does It Improve Accuracy And Increase Confidence In Diagnosing Breast Tumours?

Objective To determine the effect of Precision Imaging (PI), an innovative speckle reduction algorithm, on the diagnostic efficacy in breast ultrasound Material and methods Patients aged from 20 to 84 years screened by the breast clinic from October 2010 to June 2011 were included in this research. The commercial ultrasound scanner Toshiba AplioMX, with compact linear transducers 15-7MHz and 12-5 MHz was used for image acquisition. A single projection image that was considered to best represent the lesion was recorded without PI (L0), then with all other 3 levels of PI, namely Precision 1 (L1), Precision 2 (L2) and Precision 3 (L3), with higher numbers signifying greater speckle reduction. Fifty one breast lesions (20 malignant and 31 benign) were selected from over 200 collected lesions, with selection criteria based on the 1- 5 classification system developed by National Breast Cancer Centre in collaboration with the Royal Australian and New Zealand College of Radiologists. These selected images were cropped to remove the technical details, which included patient information as well as PI level. These processed images were then organised into four sets (A,B,C,D) with images in same PI level. These four sets of images were evaluated by six radiologists and six sonographers dedicated to breast imaging, scoring each lesion between 1 and 6.These scores were subjected to Q-Perform software, DBMMRMC, Mann-Whitney U-test, Wilcoxon Signed rank test and IBM SPSS statistics for statistical analyses. Results The overall means ROCAUC for L0 was 0.79, L1 was 0.80, L2 was 0.81, and L3 was 0.81. The overall means sensitivity for L0 was 0.75, L1 was 0.79, L2 was 0.80, and L3 was 0.78.Overall means specificity for L0 was 0.74, L1 was 0.72, L2 was 0.73, and L3 was 0.71. Conclusion The data analysis on ROC, sensitivity, and specificity did not demonstrate any significant improvement in diagnostic efficacy amongst expert observers in this study

Hidden Voices: A Qualitative Study of Cervical and Breast Screening Experiences for Women with Mild Intellectual Disability Living in the Community

This paper reports on the issue of gynaecological screening for women with intellectual disability living in the Australian community. A qualitative study using grounded theory was conducted with data collected through semi-structured interviews and focus groups. The participants were 31 women with mild intellectual disability and four of their carers, with some additional information contributed by health professionals. Themes emerging from the data identified barriers to cervical and breast screening services, as well as factors that appeared to facilitate the participants' access to screening. The study found three sets of linked factors influencing screening impetus. These were participant attributes such as knowledge level and ability to assess own risk, the relationships of the clients with significant others such as paid and unpaid carers, and health service provider behaviours that promoted respectful individualised consultations with adequate time for communication, explanation and education. Conclusions from this study were that gynaecological screening of disadvantaged groups is likely to be increased by health education programs for consumers, as well as their carers and health service providers which focus on the specific issues for this group. The study also confirms what is already known from disease prevention campaigns aiming to improve screening and immunization rates: That proactive strategies such as health professionals offering gynaecological procedures in a sensitive manner to clients and registers that send out consumer reminder letters can substantially improve screening rates and support this consumer group's right to quality of life

What is the impact of TRAM flap breast reconstruction on self-esteem and perceived body image for women with breast cancer?

Breast cancer is the most common of all cancers in women (26%) in Australia (Australian Institute Health Welfare AIHW, 1996; National Breast Cancer Centre NBCC, 1999). It is estimated that the lifetime incidence of one in eleven women in Australia will be diagnosed with breast cancer by the age of seventy-four (National Health and Medical Research Council NHMRC, 2000). Surgical resection continues to be the mainstay of treatment for early breast cancer, with approximately 50% of women diagnosed with breast cancer undergoing mastectomy (NBCC, 1999). Both the diagnosis of breast cancer and subsequent mastectomy raises a number of psychosocial issues for women. In addition to the diagnosis of a potentially life threatening illness, these women contend with the psychological consequences that accompany the loss of a breast. During the height of development of breast reconstructive techniques in the 1980\u27s, mastectomy became more commonly recognised as an important aspect of a woman\u27s experience with breast cancer. Breast cancer not only causes pain, suffering and the possibility of death, but also threatens a woman\u27s self-concept, self-esteem and feminine identity through its attack on her body (Derogatis, 1986). To reduce the psychological impact associated with removal of the breast, breast reconstruction is increasingly being offered. In the past five years there has been an increase in the number of women seeking breast reconstruction, with an increasing focus on quality of life issues and survivorship for women diagnosed with breast cancer (Wilkins et al., 1995). To date little is known about women\u27s experiences of undergoing breast reconstruction. Using a qualitative, exploratory descriptive approach this study investigated the impact of the transverse rectus abdominis musculocutaneous (TRAM) flap breast reconstruction, on self-esteem and perceived body image for women with breast cancer. In depth semi-structured interviews, using both individual and focus group methods, were undertaken with ten women who had undergone a TRAM flap breast reconstruction between January 1st 2001 and January 1st 2003. Data was analysed using the process of thematic analysis to determine key concepts and themes that described these women\u27s experiences. Three main themes emerged from the findings of this study: Loosing a breast matters , \u27\u27The process of adjusting to a changing body image , and Redefining normality . These themes and their sub-themes describe the experience of breast cancer survival and TRAM flap breast reconstruction for the women who participated in this study. These findings will further the current knowledge base on this topic and therefore assist nurses in providing sound information and psychosocially appropriate support to TRAM flap breast reconstruction patients and their significant others. Furthermore, this study\u27s findings will be a further resource for women considering breast reconstruction treatment options following mastectomy