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EDITORIAL BACK TO CONTENTS
Cathy O’Leary | Editor
WA makes its own luck Hindsight is a wonderful thing. Our State has come through in relatively good shape, so it is pretty tempting to say it was all overkill, but what if things had gone really pear-shaped?
Can anyone remember the two years leading up to March this year, when people tuned into daily press conferences in Perth with baited breath to hear if we had even a single case of COVID? And when there was a case, there was a mad panic as we were warned where that poor unsuspecting soul had visited in previous days – where they shopped or bought petrol – and be told to isolate if we had crossed paths. New case numbers are now routinely hovering around 5000 a day and there are no big announcements any more. But even if it now seems ludicrous that a city with a population of more than 2 million was thrown into lockdown because of a couple of cases, context is important and many experts argue we were right to be hyper-vigilant at the time. Hindsight is a wonderful thing. Our State has come through in relatively good shape, so it is pretty tempting to say it was all overkill, but what if things had gone really pear-shaped? Unlike most jurisdictions around the world where COVID hit like a slow tsunami and authorities scrambled to vaccinate populations that were sitting ducks, we went from zero to full throttle in a highly vaccinated population. The COVID experience in WA will no doubt form the subject of international studies. Now we’re getting on with life, albeit with a close eye on those pesky COVID variants, and that’s a good thing. We are the lucky State, but it didn’t happen by chance.
SYNDICATION AND REPRODUCTION Contributors should be aware the publisher asserts the right to syndicate material appearing in Medical Forum on the mforum.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publisher for copyright permission. DISCLAIMER Medical Forum is published by Medforum Pty Ltd (Publisher) as an independent publication for health professionals in Western Australia. Neither the Publisher nor its personnel are medical practitioners, and do not give medical advice, treatment, cures or diagnoses. Nothing in Medical Forum is intended to be medical advice or a substitute for consulting a medical practitioner. You should seek immediate medical attention if you believe you may be suffering from a medical condition. The support of all advertisers, sponsors and contributors is welcome. To the maximum extent permitted by law, neither the Publisher nor any of its personnel will have any liability for the information or advice contained in Medical Forum. The statements or opinions expressed in the magazine reflect the views of the authors and do not represent the opinions, views or policies of Medical Forum or the Publisher. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the Publisher or its contributors for the promoted product, service or treatment. Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Competition and Consumer Act 2010 (Cth) as amended. All advertisements are accepted for publication on the condition that the advertiser indemnifies the Publisher and its personnel against all actions, suits, claims, loss or damages resulting from anything published on behalf of the advertiser. EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers. Medical Forum has no professional involvement with advertisers other than as publisher of promotional material. Medical Forum cannot and does not endorse any products.
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Inside this issue 14 20
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FEATURES
IN THE NEWS
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Cancer centre to transform care Viral overload Push on for a CDC
Editorial: WA makes its luck – Cathy O’Leary
4 News & Views 6 In brief 27 Lifting our game
Music, medicine in perfect harmony
LIFESTYLE
for stroke patients – Professor Bernard Yan & Kelvin Hill
56 Take a guided tour of autopsies 60 Wine review: Nikola Estate
30 Does sleep ward off dementia? – Dr Camilla Hoyos
36 Doctor suicide a present danger – Dr Katrina Calvert
39 Room for optimism – Dr Joe Kosterich
– Dr Martin Buck
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CONTENTS
PUBLISHERS Fonda Grapsas – Director Tony Jones – Director tonyj@mforum.com.au
Clinicals
EDITORIAL TEAM Editor Cathy O'Leary 0430 322 066 editor@mforum.com.au Production Editor Jan Hallam 08 9203 5222 jan@mforum.com.au
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How new cancer therapies reach patients Adj Assoc/ Prof Tim Clay
Evolution of geriatric oncology Dr Azim Khan
Advances in lung cancer radiology treatments Dr Nicholas Bucknell
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De-escalating surgical management of axilla in breast cancer Dr Helen Ballal
Research to improve outcomes in childhood cancer Dr Santosh Valvi
Mental disturbance in perinatal period Dr Caroline Crabb
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The overactive bladder Dr Elayne Ooi
Resistance exercise: defence against sarcopenia Dr Cassandra Smith & Dr Marc Sim
Journalist Eric Martin 08 9203 5222 eric@mforum.com.au Clinical Editor Dr Joe Kosterich 0417 998 697 joe@mforum.com.au Marketing Quinn Hampton quinn@mforum.com.au Graphic Design Ryan Minchin ryan@mforum.com.au ADVERTISING Advertising Manager Andrew Bowyer 0424 883 071 andrew@mforum.com.au Clinical Services Directory Andrew Bowyer 08 9203 5222 andrew@mforum.com.au CONTACT MEDICAL FORUM Suite 3/8 Howlett Street, North Perth WA 6006 Phone: Fax: Email:
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Democracy and health Dr Michael Watson
When doctors say no to abortion Meagan Roberts
Why pronouns matter Blake Cavve & Xander Bickendorf
New Quit campaign Melissa Ledger & Sarah Beasley
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Baby steps for IVF WA women are trialing world-first IVF technology that allows them to monitor their hormone levels at home and could give better access to IVF for regional women. The women are participating in a feasibility study by City Fertility Group’s national medical director Professor Roger Hart and specialists at Fertility Specialists of WA. Professor Hart, who is also head of the reproductive medicine service at King Edward Memorial Hospital and Professor of Reproductive Medicine at UWA, said they were recruiting 25 patients to monitor hormone levels in an IVF cycle via urine samples that can be done at home. If effective, this part of the IVF process, which currently requires patients to visit a clinic for regular blood tests, will save time and stress, and for some will overcome logistical challenges to undergo monitoring in an IVF cycle. “If this at-home device proves feasible it will open IVF up to regional patients, fly-in fly-out workers and those in rural locations, lessening the burden of having to travel long distances to a clinic for blood tests in between juggling work,” Professor Hart said.
Diabetes grants up for grabs WA researchers are being offered the chance to secure a grant to channel into a diabetes-related research project through Diabetes Research WA’s annual grants program for 2023. The charity, which runs on the generosity of its donors, is offering one $60,000 research grant to a WA-based medical researcher, but more than one grant could be offered. The winner will be announced around World Diabetes Day on November 14 and application details can be found at www.diabetesresearchwa.com.au. Submissions close on August 15.
Smarter referrals WA Health is moving to replace its current process for handling external referrals to its public hospitals, with a new system known as Smart Referrals WA. It is designed to streamline the referral process and improve the accuracy of referrals received from GPs and other external service providers. Referrals to metropolitan WA public hospitals are currently processed by the Central Referral Service, which is staffed by nurses and clerical staff. While electronic referral forms 4 | AUGUST 2022
are available through GP practice management systems, only about 26% are sent via secure messaging. About half of referrals submitted to CRS need additional work because of missing information, faxed referrals missing pages, referrals not meeting required criteria and illegible handwriting.
Pulling on the heart strings Cancer Council WA’s Make Smoking History Program has launched a new emotive campaign, in a bid to prompt people who smoke to quit. ‘Worried About You’ is a narrative campaign that focuses on a daughter’s concern about her father becoming ill from smoking. Cancer Council WA’s cancer prevention and research director Melissa Ledger said the campaign aims to remind people who smoke about the worry that it causes their loved ones, and to motivate people to quit smoking. See Guest Column on P34.
DNA clues under focus Findings of a new Parkinson’s disease study in WA have opened up a new avenue for developing therapeutics to intervene in the
progression of this common movement disorder. A recent article in Experimental Biology and Medicine looked at genetic processes underlying nerve cell degeneration in people with Parkinson’s. The study, led by Professor Sulev Koks at WA’s Perron Institute for Neurological and Translational Science and Murdoch University, found that alterations in the nascent transcription of introns (pertaining to DNA sequencing) may be indicators of risk and progression of Parkinson's. “Better understanding of the mechanisms underlying the degeneration of nerve cells can help in developing targeted therapies for people with Parkinson’s,” Professor Koks said. “For many years the search for DNA risk factors for specific diseases such as Parkinson's has focused on exons – the 2% of our genome that encodes the information for proteins. The bulk
continued on Page 6
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Advancing cancer treatment and care through research
Our investment in health and medical research is central to how we deliver exceptional patient care and is supported by all St John of God Subiaco Hospital oncologists. Of our 77 active clinical trials, 50 are specific to oncology, with research investigating breast, colorectal, pancreatic, gynaecological, lung, prostate and brain cancers, as well as melanoma. All St John of God Subiaco Hospital oncologists and cancer specialists are involved in research and many have contributed to Western Australia having among the best survival rates worldwide for pancreatic, stomach, ovarian and colon cancers. In fact, we are the highest recruiter worldwide for a number of ovarian and pancreatic clinical trials and can provide patients access to new treatments before they become widely available. Almost 1,000 Western Australians affected by cancer have benefited from clinical trials led by St John of God Subiaco Hospital specialists.
Research Week 2022 You are invited to attend our hospital’s annual Research Week, Monday 22 to Thursday 25 August 2022. The week offers a diverse range of in-person and online events, and will showcase current research, new discoveries, treatments and case studies. For information about the event, please visit sjog.org.au/researchweek
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NEWS & VIEWS Obstetrician gynaecologist Dr Chhaya Mehrotra has joined the team at Western Ultrasound for Women.
Professor Andrew Turpin is the inaugural Lions Curtin Chair in Ophthalmic Big Data, a joint appointment by the Lions Eye Institute and Curtin University. He will take up the post in November.
The Perron Institute has launched a new award, the Byron Kakulas Medal, celebrating innovation in health and medical research, in honour of its founding director Emeritus Professor Byron Kakulas.
Associate Professor Juliana Hamzah has received $496,715 from Perkins Institute and Curtin Health Innovation Research Institute to commercialise the first drug to dissolve arterial plaque. Perkins vascular engineering researcher Nik Bappoo has received $500,000 to help market a device to improve the success rate of cannulas.
Telethon Kids Institute and UWA autism researcher Dr Gail Alvares has won a WA Government Future Health Research and Innovation Fund translation fellowship to lead work into early anxiety intervention for children with autism and their families.
Clinical audiologist and lead researcher at Ear Science Institute Australia Dr Bec Bennett is a finalist in the 2022 Premier’s Science Awards for her work into the social, emotional and psychological impact of hearing loss.
continued from Page 4 of the DNA risk resides in the other 98% of the genome that determines where, when and for how long exons are produced to generate these proteins. “Similarly, previous research has focused on the measurement of exons in specific cells, ignoring the bulk of non-exon material that can affect their function.” In other news, a team led by Professor Koks is trying to identify potential gene therapy for aggressive bone cancer. Malignant osteosarcoma begins typically in the long bones of the legs and arms and can spread to other areas. It occurs disproportionately in teenagers and young adults.
Making a beeline for pain relief A Perth Children’s Hospital research team is buzzing following their success in the recent Australian Clinical Trials Alliance Awards 2022. The anaesthesia research team won the runner-up award in the consumer involvement category for their Bee Pain Free trial. It evaluated the effectiveness of honey as a natural pain management treatment for children after tonsillectomy. The team developed a randomised control trial to investigate the pain management properties of different types of local honey taken for seven days after the operation. The trial involved 400 children
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Silica dust threat As many as 10,000 Australians are predicted to develop lung cancer in their lifetime from being exposed to silica dust, new Curtin University modelling has found. It comes amid warnings more than half a million workers are currently exposed to the harmful dust. Engineered stone – used mainly for kitchen benchtops – is a potent source of silica dust. The dust is also found naturally in many building and construction products including sand, soil, stone, concrete and mortar, as well as being used in the manufacture of building products such as bricks, tiles and glass. For the past 60 years, silicosis had been rare in Australia but continued on Page 8
across PCH, Fiona Stanley Hospital and St John of God Subiaco. All children were followed up for two weeks post-surgery. Research began with clinical care audits of hundreds of families after one of the most common childhood surgeries. The ongoing postoperative pain issues of children, combined with many parents’ reluctance to use strong pain relief medications at home, prompted the search for effective, natural solutions. Professor Britta Regli-von UngernSternberg said the burden of pain management was falling on parents. “We knew that honey has been a valued medication since ancient Egypt, known for its antiinflammatory, analgesic, antioxidant properties, and we thought it would be a good topical treatment for children,” she said. “It also coats the back of the throat and makes swallowing easier.” MEDICAL FORUM | CANCER CARE
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NEWS & VIEWS
the increased use of engineered stone in kitchen benchtops is driving a re-emergence of the disease, prompting the Australian Government to set up the National Dust Diseases Taskforce. In June, Safe Work Australia also released a consultation regulation impact statement that proposes options for managing the risks of exposure and is open for public submissions.
Don’t forget this test New research from Edith Cowan University has revealed a simple, common test can reveal if people are at increased risk of developing dementia late in life. About 600,000 bone density tests are performed in Australia each year to screen for osteoporosis but they can also show whether plaques have built up in the abdominal aorta. The ECU team found that abdominal aortic calcification was a reliable marker for late-life dementia. This meant doctors could use an alreadycommon test for early detection of a person’s dementia risk and try to delay the onset.
Tweaking steroid use in pre-term bubs
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A WA research program aimed at optimising steroid use in pregnancy has generated important preclinical data showing how the gold-standard antenatal steroid treatment regime for preterm infants could be improved. Researchers from the Women and Infants Research Foundation, the National University of Singapore, Cincinnati Children’s Hospital and Tohoku University Hospital have been working to improve the lung maturation of preterm infants and minimise potential side effects to both mother and baby. They have found that in preterm lambs, using just one-third of the current steroid dose was highly effective in improving lung function, while having significantly fewer side effects for neonates. The use of steroid therapy in pregnancy to rapidly mature the fetal lung, making breathing easier and safer for preterm babies, has been responsible for saving the lives
of thousands of preterm babies. WIRF acting chief scientific director Professor Matt Kemp (above) said the findings represented a major breakthrough in the field of obstetrics. “While we eagerly await the clinical trial data, the findings of this study strongly indicate that a low-dose betamethasone treatment regimen will likely perform better than the current, higher-dose dexamethasone phosphate regimen,” he said.
LETTER TO THE EDITOR Dear Editor, I am writing in response to the article “Restrictive practices and government over-reach” published in the May 2022 edition of Medical Forum, to correct several inaccuracies. First, the examples of restrictive practices cited by Dr Roberts are not regulated restrictive practices as they relate to children and as such, this misinformation is unhelpful to NDIS participants and their families, and to providers. Secondly, Dr Roberts’ views regarding behaviour support practitioners and AHPRA, and the proposal to amend the ‘Act (the Children Rules)’ are incorrect. The National Disability Insurance Scheme Act 2013 (NDIS Act) and the NDIS (Restrictive Practices and Behaviour Support) Rules 2018 are intended to provide safeguards for all NDIS participants and to work towards the reduction and elimination of restrictive practices which have a significant impact on a person’s human rights. There is, of course, no proposal to change that. Importantly, the regulatory role of the NDIS Commission applies to NDIS providers, not in the context of families. As such, there is no government overreach as suggested by Dr Roberts. We have published practice guides on
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what constitutes a regulated restrictive practice, including for children and young people, which can be found on our website – Resources |NDIS Quality and Safeguards Commission (ndiscommission.gov.au). For the first time in Australia, we have put in place the regulation for behaviour support providers. It is useful to highlight that behaviour support providers engage practitioners who come from diverse professional disciplines, such as psychology, speech pathology, occupational therapy, developmental education, social work and applied behaviour analysts. Many of them have undergraduate and or post-graduate qualifications. The NDIS Commission has practice standards and obligations that behaviour support providers are required to meet, including the NDIS Code of Conduct. It is important that we collaborate with relevant professionals to ensure the wellbeing and safety of NDIS participants. Central to this is that they have accurate and sound information. Dr Jeffrey Chan Senior Practitioner, NDIS Quality and Safeguards Commission
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The The National National Bowel Bowel Cancer Cancer Screening Screening Program: Program: using using evidence evidence to to save save lives lives Hooi Ee, MBBS, PhD, FRACP, is Hooi MBBS, PhD, FRACP, is HeadEe, of the Gastroenterology Head of the Gastroenterology Department at Sir Charles Department at Sir Park Charles Gairdner Osborne Gairdner Osborne Park Health Care Group and a Health Groupinand a ClinicalCare Professor Medicine Clinical Professor of in Western Medicine at The University at The University of Western Australia. He is an actively Australia. is an actively practisingHe clinician, teacher, endoscopic trainer and practising clinician, teacher, endoscopic trainer and research collaborator. He is the Clinical Lead of the research collaborator. HeReference is the Clinical Lead of the Bowel Cancer Screening Group in WA Health, Bowel Cancer Screening Reference Group in WA and is a Clinical Expert on the Quality CommitteeHealth, of and is a Clinical Expert on the Quality Committee of the National Cancer Screening Registry. He currently the National Cancer Screening Registry. He currently co-authors NHMRC Guidelines on bowel cancer co-authors NHMRCbowel Guidelines bowel cancer screening, familial canceron and colonoscopic screening, familial bowel cancer and colonoscopic surveillance. surveillance.
Australia has one of the highest rates of colorectal Australia one ofwith the highest rates of colorectal cancer in has the world, 1300 diagnoses and 400 deaths cancer in the world, with 1300 diagnoses 400isdeaths in Western Australia each year. Colorectaland cancer in Western Australia each year. Colorectal cancer is Australia’s second biggest cancer killer, but if detected Australia’s second biggest cancer killer, but if detected early, more than 90% of cases can be successfully early, more 90% Bowel of cases can be successfully treated. Thethan National Cancer Screening Program treated. The National Bowel Cancer Screening (NBCSP) mails home test kits (immunochemicalProgram faecal (NBCSP) mailstest, home test to kits (immunochemical faecal occult blood iFOBT) Australians aged 50-74 occult blood test, iFOBT) to Australians aged 50-74 every two years and is one of the most important every two years and is one of the most important Commonwealth public health programs. Commonwealth public health programs. NBCSP participation is at 45.9% in WA – the national NBCSP participation is at 45.9% in WA –participation the nationalto rate is even lower at 43.5%. Increasing rate evenresult lowerin at84,000 43.5%.Australian Increasinglives participation 60%iscould saved overto 60% could result in 84,000 Australian lives savedby over 25 years. On 20 June, Cancer Council (supported the 25 years. On 20 June, Cancer Council (supported by the Australian Government) launched the Get2it campaign Australian Government) launched the Get2it campaign aiming to increase NBCSP participation by 4% during the aiming to increase NBCSP participation bycomponents 4% during the campaign period. The campaign includes campaign period. The campaign includes components targeted specifically towards Culturally and Linguistically targeted specifically towards Culturally Linguistically Diverse and Aboriginal and Torres Straitand Islander Diverse and Aboriginal and Torres Strait Islander Australians, two groups with low participation rates Australians, two20-30%). groups with low participation rates (approximately (approximately 20-30%). The role of GPs in improving participation is evident The of GPs in improving participation is evident givenrole 92% of people nominate their GP as the most given 92% of people their GP asGPs thecan most influential source of nominate NBCSP information. act influential source of NBCSP information. GPs can act as advocates and support their patients to Get2it and as advocates and support their patients to Get2it and
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do the test. Useful resources are available at do the test. Useful resources are available at www.bowelcancer.org.au/gp www.bowelcancer.org.au/gp Colorectal cancer screening works - there is significant Colorectal cancer screening works - there is significant evidence underpinning the NBCSP: evidence underpinning the NBCSP: • A positive NBCSP iFOBT occurs in 7% of participants • A positive NBCSP iFOBT occurs in 7% of participants and is 60 times more likely to find colorectal cancer and is 60 times more likely to find colorectal cancer than a negative result. than a negative result. • Colorectal cancer is found in 3.5% of positive iFOBT • Colorectal cancer is found in 3.5% of positive iFOBT results. results. • Cancers detected through the NBCSP are detected at • Cancers through to thesymptomatic NBCSP are detected an earlierdetected stage compared cancers.at an earlier stage compared to symptomatic This translates to a 15% mortality reductioncancers. after This translates to a 15% bias. mortality reduction after correcting for lead-time correcting for lead-time bias. • Less than 10% of colonoscopies performed are due to • Less than 10% of colonoscopies performedresources are due to the NBCSP, so the impact on colonoscopy is the NBCSP, so the impact on colonoscopy resources is minimal. minimal. The NBCSP is more efficient and has a higher yield The is more efficient and colonoscopies has a higher yield thanNBCSP large numbers of low value being than large numbers of low value colonoscopies performed. Colonoscopy requests arising from abeing positive performed. Colonoscopy requests arising from a WA positive iFOBT are considered triage Category 1 through iFOBT are considered triage Category 1 through WA Health direct access pathways. The NBCSP also requests Health direct access pathways. TheGPs, NBCSP also requests outcome report submissions from colonoscopists and outcome report submissions from GPs, colonoscopists and histopathologists as part of data collection. The National histopathologists part of (NCSR) data collection. TheProvider National Cancer Screening as Register’s Healthcare Cancer Screening Register’s (NCSR) Healthcare Provider Portal (HPP) provides a self-service alternative for health Portal (HPP) provides a self-service health professionals to access and submit alternative bowel (and for cervical) professionals to access and submit bowel (and cervical) screening data electronically via a PRODA login. More screening data via aNCSR. PRODA login. More information canelectronically be found at the information can be found at the NCSR. Looking ahead, the incidence of early onset colorectal Looking ahead, the incidence of early onset colorectal cancer (diagnosis prior to 50 years of age) has been cancer (diagnosis years of now age)makes has been increasing over theprior lastto 3050 years and up 10% increasing over the last 30 years and now makes up 10% of colorectal cancer cases. The expansion of the NBCSP of colorectal cancer cases. The expansion of the NBCSP to start screening at 45 years of age is a major discussion to start screeningon atcost 45 years of age is aresourcing, major discussion area, dependent effectiveness, and area, on cost effectiveness, resourcing, and accessdependent to downstream services. access to downstream services. Colorectal cancer screening works. It is efficient, Colorectal cancer screening It is efficient, cost effective, and saves lives. works. Encouraging greater cost effective,inand lives. participation thesaves NBCSP willEncouraging advance thegreater primary participation the NBCSP will reducing advance the screening goalinof substantially the primary incidence, screening of substantially reducing the incidence, morbidity,goal and mortality of colorectal cancer in Australia. morbidity, and mortality of colorectal cancer in Australia.
AUGUST 2022 | 9
Democracy and health WA’s state of emergency orders need winding back for the sake of our democracy, writes Dr Michael Watson.
“In talking to colleagues, a consistent message is that they are simply not being listened to and that a small handful of people in the government bureaucracy are dictating all of the critical decisions that are being made... ”
Have you ever asked yourself why Australia has consistently outperformed most countries in times of crisis? COVID is just the latest example of an Australian success story. Sure, you can argue that our geographic isolation and rich natural resources gives us an advantage, but that is only part of the story. Freedom of thought and democracy are the key reasons for our success and the underlying value system required for a successful democracy is Respect (empathy and compassion i.e. understanding and kindness). You cannot be a successful democratic leader unless you have a good understanding of your community members’ individual needs and an overwhelming desire to be kind to them. You may have noticed that over the course of the COVID pandemic the decision-making process in Australia has progressively decentralised and with that process the quality of the decision-making has improved as individual states, regions and organisations adapted the COVID rules to meet their individual needs. Some of the crazy policies early in the pandemic such as the banning of asymptomatic COVID testing of people having elective surgery (when there was an abundance of PCR testing capacity) and the discouragement of the use of protective mask wearing in the community gave way to more sensible approaches that we see today where high-risk groups are actively protected and others are allowed to have freedom of choice. So why did things change for the better over time? It was simply that our community leaders behind the scenes put pressure on government bureaucracies to change what they were doing. I can tell you that in Western Australia, the majority of the early expansion in PCR testing for COVID did not come about through government support, but through the mining industry who had to use brute force of political will to demand to be allowed to do asymptomatic screening of their workers travelling to mine sites. They then worked with private medicine to fund and deliver those services, which benefited not only the mining industry, but our entire community. Unfortunately, strong recommendations by the AMA and other community leaders in health were unable to persuade government bureaucrats to allow for the asymptomatic testing of patients undergoing elective surgery early in the pandemic (something which is now, of course, mandatory). Mask-wearing on planes was also suggested by the mining industry who had to fight hard to be allowed to do it. It took a long time for government
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NEWS & VIEWS
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NEWS & VIEWS bureaucracies to realise the benefits of this and to recommend it for all Australians. Closing the borders (which I believe was the single most important action to protect Western Australians) was not originally a government idea – it resulted from political pressure brought to bear on the government bureaucracy by the AMA and other community leaders in health. Most recently I was involved in lobbying the government bureaucracy for a sensible system for the distribution of COVID antivirals. Despite the support of key community leaders, our suggestions were simply ignored by these bureaucrats who mandated the use of an inefficient centralised government system, potentially delaying the efficient distribution of life-saving medications which should have occurred through traditional, well-established community pathways. These are just a few of the examples that I am aware of, but in talking to colleagues, a consistent message is that they are simply not being listened to
and that a small handful of people in the government bureaucracy are dictating all of the critical decisions that are being made, not infrequently making decisions which are contrary to health and other community leaders’ advice. The government bureaucracy would argue that the Emergency Management Act 2005 (WA) and the Public Health Act 2016 are required to safeguard Western Australians and certainly it is true that we need collectively enforceable rules in crises. However, these pieces of legislation need to be urgently repealed and amended to protect our democracy. The reality is that placing power and decision-making into the hands of a tiny number of government bureaucrats (which this legislation does) in crises, may actually slow and impoverish our communities’ responses. Empowering our democratically elected community leaders in our professional societies and other key groups through legislative reform to legally give them a greater say in times of emergency will safeguard our community from
poor government decision-making in the future. Those of us who have actively lobbied governments to help them to make sensible public health policy are tired of having our suggestions ignored and, worse, at times being intimidated to keep quiet when our community is at risk from poorly thought-through government interventions. We must all demand that the Emergency Management Act 2005 (WA) and the Public Health Act 2016 be immediately repealed or urgently amended to protect our society’s democracy and our community’s health. We need a more Respectful (empathetic and compassionate) approach to dealing with crises and this only comes about through a strong democracy which promotes the value of Respect (understanding and kindness). We must insist that the value of Respect be enshrined in our legislative system to protect the health and wellbeing of all West Australians. ED: Dr Watson is a Public Health Advocate, Valued Voice
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Cancer centre will transform service
If funding and construction stay on track, by 2024 Western Australia will have a ‘one stop shop’ for cancer care that will change the landscape for both patients and clinicians.
Cathy O’Leary reports For many cancer patients, if they tracked their treatment plan on a street map there would be lines everywhere – a multitude of locations where they had to go for tests, surgery, chemotherapy and support services. Now WA’s health system is moving a step closer to offering a different model – a ‘one stop shop’ for cancer care that will mean less disjointed treatment and a more integrated approach. In March, the Commonwealth committed $375 million to a $750 million dedicated cancer hospital based at the QEII Medical Centre campus. It is scheduled to open in 2024, although the project is still dependent on additional funding, including a contribution from the State Government. Plans for the 10-storey centre include 300 beds and treatment chairs, 140 overnight and inpatient beds, 110 chemotherapy medical beds and chairs, operating theatres, an intensive care unit, pharmacy, medical imaging service and even a gymnasium. The new facility, which is being developed by the Harry Perkins Institute, will ensure world-first cancer medicines and clinical trials, supportive therapies, an integrated ICU as well as hospital beds solely for cancer patients will be in one location. It is based on a holistic philosophy already used by the likes of the Peter MacCallum Cancer Centre in Victoria and the Chris O’Brien Lifehouse in New South Wales.
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FEATURE The WA centre will service public and private patients and have outreach into regional WA, including Indigenous communities. Cancer accounts for more than 158,000 hospital admissions a year in WA – or almost 15% of all hospitalisations. While standards of clinical care are generally high, many patients find their cancer journey can be fragmented, causing delays in treatment and sometimes the need travel to the eastern states to receive care. Few medical professionals understand the need for a comprehensive cancer centre more than Associate Professor Shannon Simpson who has survived cancer twice – all before the age of 40. The co-head of the Children’s Lung Health research team at the Telethon Kids Institute and Curtin University was diagnosed with breast cancer in 2009 when she was in her late 20s and living in Melbourne doing her PhD. She later moved to Perth to continue her research in respiratory physiology and, in 2013, when she was aged 33, the cancer returned, this time in the top of her femur. Unlike the seamless treatment in Melbourne at the then Austin Hospital (now the Olivia Newton John Cancer Centre), in Perth she had to navigate her way between at least eight different medical centres and multiple health professionals. Even as a medical professional she felt overwhelmed navigating the system, with some treatment appointments booked for the same time in different locations. “When I went through my second round of cancer, I had surgery in one hospital, rehab in another hospital and chemo in another two, and then I ended up seeing a specialised oncology psych service at a different hospital again,” she told Medical Forum. “With my first lot of treatment in Melbourne there was a more holistic style of care, and because I was in my 20s when I was undergoing that treatment, they made sure that when I came in for my chemo, for example, they would have a young MEDICAL FORUM | CANCER CARE
survivors’ morning, so we all had our treatment together and formed a peer network. “We were able to talk about what was going on for us, when there were so few other ways to get connected to people going through a similar experience. A social worker would come in and do some guidance stuff with us and the women in the group were put through a ‘look good, feel better’ program, learning how to put on make-up when you don’t have hair or eyebrows or lashes – things that can really help during your cancer journey.” Prof Simpson said that because of her experiences, in her own area of research – children born preterm – she made sure families and people with lived experience sat alongside the research program. “I’ve seen big changes in cancer care over the past 10 years or so, since my foray into the health system with cancer 13 years ago,” she said. “There are still a number of gaps that need to be addressed and my hope would be that the comprehensive cancer centre will take us a step closer to addressing some of them. “Having all those services under one roof would be absolutely amazing. It would take away a huge burden of having to manage all of them and be quite a relief.” As far as her own recovery is concerned, she says she is regarded as a bit of an anomaly. Because she was diagnosed with stage 4 metastatic diagnosis in 2013, she had less than a 5% chance of survival beyond five years. But next year it will be 10 years since her treatment and she has no sign of cancer. “While no one will actually say I’m cured, I’m certainly living very well without any evidence of disease, so I’m very grateful for that,” she said. “But it’s never a one-time journey for anyone with cancer, as there’s always the risk that the cancer will come back at some point, and that’s exactly what happened with me – my second diagnosis was a metastatic recurrence.
“But even if it hadn’t come back, cancer never ends when your chemo and radiation finish, there’s this lifetime of follow-up and all the other considerations.” She said for young women, cancer can mean going through menopause because of chemotherapy and then having bone density issues their whole life. “The treatments that you’re given are pretty brutal and do lead to lifelong consequences, especially when you have them when you’re younger,” she said. “The side effects are harsh, and of course when you’ve had treatment for cancer, you’re more likely to have another cancer because the treatments themselves can cause cancer, so it’s a bit of a tricky space.” Perkins’ director Professor Peter Leedman said the new cancer centre was a visionary investment that would help transform cancer treatment, care and research in WA, leading to improved patient survival and quality of life. It would allow WA to be part of an integrated national network of comprehensive cancer centres around Australia being developed by the Australian Government’s Cancer Australia agency. It would hopefully help prevent a ‘brain drain’ of doctors, nurses and other professionals leaving WA for other cancer centres in the eastern states. Prof Leedman said it would help enhance the QEII precinct as a medical centre of excellence, complementing the Perth Children’s Hospital, Sir Charles Gairdner Hospital, Telethon Kids Institute, the Perkins Institute, PathWest and the new maternity hospital. “Until now, Western Australia was the only mainland State in Australia that did not have a truly comprehensive cancer centre in operation or in development,” he said. “As with any project of this scale, there is still a lot of work to do to get the centre built and running to service the community, but this is a huge and significant move. There's a growing network of comprehensive cancer centres across Australia, and we want to be a part of that.”
AUGUST 2022 | 13
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FEATURE
Viral overload There are lessons to be learnt from the pandemic, including how we should never be complacent about the potential for viruses to cause mayhem.
Eric Martin reports COVID has been the most significant health event this century and the way the virus has evolved has not only changed the narrative of disease prevention, but also the way that society views the risks posed by deadly pathogens with epidemic potential. And with the increasing emergence of a wide range of respiratory viruses, not to mention other diseases such as monkeypox and Japanese encephalitis, what lessons have we learned from COVID and how can Australia better prepare for the next global outbreak? Medical Forum spoke with epidemiologist Dr Paul Armstrong, director of the WA Department of Health’s Communicable Disease Control Branch, and viral immunologist Professor Cassandra Berry from Murdoch University, to discuss the impacts and implications of the pandemic. Dr Armstrong’s unit had oversight of the initial emergency response strategy here in WA – the Respiratory Infectious Diseases Emergency Response Plan, which was being finalised as COVID arrived. “It was an emergency response plan for respiratory infectious diseases because that's where we believed the biggest risk was, and rather than focusing on influenza, as most pandemic planning has, we focused on what was called ‘pathogen X’, which was loosely based on a SARS-type coronavirus,” Dr Armstrong said. “Of course, the response became much, much bigger, as pandemics and
14 | AUGUST 2022
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FEATURE their responses do. But in the initial phase, it was the public health side of the response that stood up pretty much immediately and the flag went up, this was a threat to the world.” Professor Berry said that at the start of the outbreak, the barrage of public messaging and press conferences were an effective way to stay updated. “We learnt new battle cries: ‘crush the virus’ and ‘flatten the curve’, but forced snap lockdowns and changing rules had some negative impacts on compliance and at times throughout the pandemic, government and medical officers were sending opposing messages, which led to confusion,” she said.
Shifting goalposts “As a professor in viral immunology, I was frustrated by the constantly changing rules, especially the social distancing measures. Viruses simply don’t obey rules – they change them – and moving goal posts from 2.5m back to 2m, or 1m distances only accommodated probability.” Dr Armstrong explained that even though clear communication to the public was one of the most important aspects of the response, it was “very, very difficult” to manage in such a swiftly evolving situation. “It's inevitable that there were mixed messages: the information was coming in at such a rapid rate that there was a necessity to change our messages, and responsibility for that communication was widespread among governments, public health experts, media, other commentators and industry as well,” Dr Armstrong said. “The border closures, for example, weren’t really anticipated, in fact, they were not included in the national pandemic influenza pandemic response plan. They were a decision made by government and came out of quite alarming information emerging from countries affected by those very early phases of COVID.” He also believed that Australia’s success in delaying the arrival of the pandemic, combined with high levels of vaccination and low mortality rates, may have reduced MEDICAL FORUM | CANCER CARE
people’s perceptions of the danger posed by the disease. “The outcome that we were all looking towards, which was lowering mortality and severe illness, actually came true,” Dr Armstrong said. “But that gave people a distorted view of COVID. “The really important point was that COVID is, for most people, a mild disease but in a small population it is very severe, and when that disease is ripping through the entire population, that small percentage ends up being a large number. “Many people didn’t realise that.” Professor Berry said that although society had somewhat succeeded in raising the awareness of viruses to the public, we could also do more, especially in addressing complacency and COVID fatigue.
Overcoming fatigue “We are becoming more impatient in living with COVID,” she said. “Once borders opened and restrictions eased, many chose to ignore caution and hurriedly booked flights to travel overseas despite the virus (Omicron subvariants BA.4 and BA.5) being prevalent in crowded airports and train stations, waiting to co-board with passengers. “We need to remember that these new subvariants can still infect us even after full vaccination regimes.” And as pandemic fatigue set in, misinformation also took its toll on compliance, though Dr Armstrong said he did not think that anyone was surprised by its emergence, particularly enabled by the ubiquity and ease of social media. “There's always going to be naysayers and conspiracy theorists, and other people are very hesitant about accepting what government says. Everybody has a different understanding of risk and how that fits their perception of their own individual circumstances,” Dr Armstrong explained. “You know that a small proportion of population is not going to be on board, but the vast majority are, and that's the way we always manage these things. “And that's the same in the vaccine hesitancy space – we know that only
1-2% of the population will refuse to get vaccinations for themselves or their children, but 98% will.” Professor Berry agreed vaccine hesitancy has been fuelled in part by ignorance and misinformation leading to mistrust, especially disseminated via social media. As the COVID-19 pandemic was evolving, it was difficult to predict the end game. She believed that a direct way to combat these myths was to provide prompt and accurate evidencebased factchecks, echoed on social media platforms to reach the same audience. “We could also teach children at primary school about viruses and infection control to raise awareness at an earlier age and build a stronger culture in the value of studying STEM,” Professor Berry said.
Do it smarter “Australia could be better prepared by placing more emphasis on higher education to train the next generation of virus hunters, vaccine designers, health-care workers and associated infection control personnel. These specialists can then collectively inform government policy, liaise with medical advisers, and develop in-house therapeutics and diagnostics.” She highlighted that even though the exact occurrence of another pandemic was unpredictable, epidemiologists believed that a zoonotic disease might emerge in our lifetime, with about 75% of new infectious diseases of zoonotic origin. The most likely pandemic agent would be a respiratory RNA virus with animal origin and airborne transmission. “Disease X will probably have various animal reservoirs, a long incubation period where infectious people are asymptomatic and a range of vectors (insects, ticks, mites) for transmission,” she said. “Many zoonotic diseases have origins in bats and non-human primate species that can easily use mammalian receptors to infect our cells, but avian influenza viruses are also common in aquatic birds and farmed poultry.
continued on Page 17
AUGUST 2022 | 15
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Viral overload continued from Page 15 “And alarmingly, numerous avian influenza viruses of low pathogenicity in poultry are only a few amino acid mutations away from becoming highly pathogenic and transmissible from human to human. “Right now, we are seeing increased cases of monkeypox outside of Central and Western Africa. Viruses are rebels and break the rules and once a virus has found a new niche in humans and can adapt with ease of human-to human transmission, the race is on.” Dr Armstrong and Professor Berry said that the three elements needed for a pandemic were low levels of population immunity, a high level of contagiousness (Ro number), and the pathogen’s potential to cause severe disease, which was why the biggest threat came from infectious respiratory diseases.
Detect, develop “What's in our favour is a much greater ability to detect them and to develop vaccines, as we've done for COVID-19, and to analyse them from a laboratory point of view in order to develop treatments and help people who are sick,” Dr Armstrong said. Professor Berry said that the genetic breakthroughs in vaccine development, from conducting pre-clinical and clinical trials, had resulted in many new vaccine designs being licensed. “One strategy to combat new viruses is to predict those with pandemic potential and create designer vaccines to have on the shelf in case of an emergency. For influenza, we can create multivalent vaccines of avian origin using our knowledge of the virus structure and assembly,” she said. “The efficacy of traditional inactivated virus vaccines can also be enhanced with new adjuvants and alongside vaccines, research into new antivirals and immunetherapeutics is also underway.” Antivirals prevent a virus from replicating in the body and keep the number of virus particles down, MEDICAL FORUM | CANCER CARE
and even though several different antivirals are always in development, the pandemic caused an explosion of research and new products brought to release. “The key information is knowing which viral targets induce protective B and T cell responses. Clever viruses have evolved to evade these protective immune responses, so knowledge of evasion tactics is also critical,” Professor Berry said. “Novel antivirals are found by understanding the replication cycles of viruses and their target sites of infection in the body, and knowledge of neutralising antibodies in convalescent sera has shed light on their specificity, which gets better at binding to the virus over time. "Synthesising such high-avidity antibodies can be used as immunoprophylaxis for those at high risk to provide immediate protection.” Dr Armstrong also pointed out the role played by whole genome sequencing, which although an existing technology, came to the fore with COVID thanks to its ability to detect variants of concern and identify sources of infection during outbreak investigations.
Genome power “Genomic sequencing has been accelerating over the past few years and more and more applications have been found for it. But in this
circumstance, it really did play a strong role in us understanding the pandemic because each of those variants behaves in a different way around severity, immune escape and transmissibility,” Dr Armstrong said. “If this happened 20 or 30 years ago, you could say potentially that this person had a pandemic virus, but you wouldn't know which type it was.” The good news, Dr Armstrong said, is that the natural history of pandemics shows that after some time, perhaps a small number of years, the waves of infection will lower and, thanks to vaccination, herd immunity should help keep new variants at bay. The bad news however, according to Professor Berry, is that other viruses are unlikely to politely take turns to cause a pandemic. “Should we be afraid?” Professor Berry asked. “Not necessarily but we should be alert and respect these viruses. We need to put into action our risk mitigation plans and curb our destructive behaviours. “Pre-pandemic strategic mindsets are better than waiting to be reactive in a state of emergency, yet as we watch global leaders on television shaking hands, we have almost forgotten the past greetings with elbow bumps.”
AUGUST 2022 | 17
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CDC – let the planning begin
The pandemic might prove to be the catalyst for our own national control-room to manage diseases and emerging infections.
Cathy O’Leary reports Long before COVID, RATs and ‘iso’ became part of the local vernacular, doctors and other health professionals had been calling for Australia to have its own Centre for Disease Control, or CDC. In principle, it was to be modelled on existing groups around the world including the Centers for Disease Control in the US, a highprofile, multi-pronged organisation that provides key advice in the management of infection and disease. However, a lack of commitment from successive federal governments has meant calls for an Australian CDC had been languishing for years, but the arrival of COVID looks to have changed that. In its pre-election push, the now Albanese Labor Government gave an undertaking it would establish the expert group, if elected. It claimed Australia’s COVID response had been undermined by ‘tragic failures’, with the country badly unprepared, including not having run a national pandemic drill since 2008. Labor claimed that Australia’s response was undermined by breakdowns in the federal system, with unhelpful attacks on some states, particularly over school and border closures. 18 | AUGUST 2022
Pledge welcomed Such endorsement for a CDC has been welcomed by many health groups, including the Public Health Association of Australia, the Australian Medical Association, and the Australian Healthcare and Hospitals Association (AHHA). They argue the centre can improve the country’s response to future infectious diseases outbreaks. The AHHA said a standing committee on health and ageing recommended back in 2013 that the Commonwealth commission an independent review to assess the case for a national centre. Instead, the Government decided to work with the states and territories to develop and endorse a national communicable disease framework, without changing the responsibilities of governments. The AHHA says the threat of new and re-emerging communicable diseases will continue to be a global challenge and public health services need to be more strategic, coordinated and nimble. Five years ago, the AMA also released a position
statement calling for the “immediate” establishment of a CDC, with a focus on current and emerging communicable disease threats using global health surveillance, epidemiology, and research. It said Australia was the only country in the OECD that did not have a national authority to combat infectious diseases, ominously warning that “diseases and health threats do not respect borders”. “A CDC is urgently needed to provide national leadership and to coordinate rapid and effective public health responses to manage communicable diseases and outbreaks,” the AMA said at the time. “The current approach to disease threats and control of infectious diseases relies on disjointed state and commonwealth formal structures, informal networks, collaborations, and the goodwill of public health and infectious disease physicians.” Dr Omar Khorshid, who recently stepped down after two years as AMA national president, told Medical Forum that while federal and state governments had MEDICAL FORUM | CANCER CARE
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FEATURE mostly done a good job in managing the pandemic, they could have been more responsive. “If we’d had a Centre for Disease Control, with a more nationally consistent approach, we wouldn’t have seen the state border issues and fighting among the premiers,” he said.
Prevention is better The Public Health Association of Australia (PHAA) wants to go a step further by giving such a new centre a clear prevention focus, to become the Australian Centre for Disease Control and Prevention. Its chief executive officer, Adjunct Professor Terry Slevin, said that for decades the PHAA had lobbied for, and written about, the need for such a centre, including running a recent webinar to discuss how it could be designed. “There have been calls for a national centre for disease control and prevention for more than 30 years, and the pandemic has simply been the catalyst to gain commitment from the ALP while they were in opposition,” he told Medical Forum. “Now in government we believe it will, and must, happen. “It is still the case that less than 2% of health funding goes into public and preventive health, and that makes no sense in 2022.” Prof Slevin said the centre would bring together public health work across communicable and noncommunicable diseases, improve consistency, efficiency and data sharing, and inject vitally needed resources into public health. “The establishment of such a centre is a once-in-a-generation opportunity to improve the public health architecture of Australia,” he said. “It is essential that it is properly thought through, structured and funded. If done well, it can bring together and better support the essential public health efforts at state and territory level.”
Doing a CDC better While there is no single definition of a CDC, broadly it is a national agency that promotes public health through the control and prevention of disease and disability. MEDICAL FORUM | CANCER CARE
The US-CDC employs more than 10,000 staff, focusing on infectious diseases, food-borne diseases, environmental health, injury prevention, health promotion, and noncommunicable diseases such as obesity and diabetes. But it has been criticised for being overly bureaucratic, lacking innovation and being missing in action during the COVID pandemic, as well as being subject to potential political interference. Proponents argue that the Australian centre needs to do better and improve how data is collated and shared between states and territories. The PHAA wants a taskforce set up and given six months to work out governance issues and resourcing to give the new public health entity the best possible chance of success. The association has even set up a specific advocacy arm – a blog called CDC Corner – to encourage discussion among its members. “We hope CDC Corner will be a valuable hub for expression and exchange of views, as well as creating a resource that may be of use to those who make the key decisions about how a centre will be designed and established,” Prof Slevin said.
experts from a broad range of sectors, which formed in response to the pandemic and has convened an independent expert panel to report on a CDC. It has foreshadowed the undertaking will present many challenges. “Although public health is primarily a state and territory responsibility, a national approach can bring effectiveness and efficiencies, especially when faced with threats that cross domestic and international borders,” it said. “In principle it should support governments – a state, territory and Commonwealth, and this requires a management system in which all governments have confidence.” OzSAGE said that ideally the centre would operate 24/7 and be responsible for responses on the ground. It would support programs such as immunisation, screening, disease surveillance and anti-tobacco measures, as well as short-term responses to emerging threats including response to cross-border or international emergencies. And while it would form some type of public sector agency, most public health functions would need to remain the responsibility of states and territories.
Among the first to take up the offer is OzSAGE, a network of Australian AUGUST 2022 | 19
Music and medicine in perfect harmony She started her life wanting to be a musician, but Emily Leung pivoted into a greater challenge – becoming a doctor.
Ara Jansen reports
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CLOSE-UP On the surface, medicine and music might seem like they have little in common, but both professions take practice, precision, an inquiring mind and a dedication to excellence. Emily Leung is already an accomplished and awarded violinist, so she actively lives those attributes. Now in her second year of medicine at UWA, she’s applying those traits to her studies on the way to becoming a doctor. Born and raised in Perth, Emily started playing the violin at age seven. It wasn’t just something to do, but a chance to emulate her older brother whom she adored – and still does. At nine she remembers going to a concert of Max Bruch’s Violin Concerto No. 1 in G minor. It was the start of a love affair with music and her violin. Years of dedicated practice later, she was playing the concerto
herself. By the time she reached double digits Emily knew she wanted to be a musician. “I wanted to be a musician simply because of the joy I had from playing, and the emotional solace I got from listening to music. Listening to some particular performances changed my life,” she says. “I knew that if I could do that for other people, then it would be a wonderful thing to do with my life. I considered medicine and other professions at the time – but I simply loved music.” Through her playing she was introduced to international violinist Karen Gomyo. Bravely asking if Karen would give her some tips, they met a few times and Karen became a mentor and inspiration to the young musician. A few years later, Emily met Karen’s
Photo: Bob Sommerville
former teacher, world-renowned pedagogue Mauricio Fuks, with whom she studied at Indiana University’s Jacobs School of Music in the US. Emily was the first international recipient of the university’s most prestigious scholarship, the Wells Scholarship. After spending four years there, she returned to Perth in 2020 to start studying medicine at the age of 22.
Why medicine? With concerts planned and an international career in music potentially beckoning, what made her give that up to go back to university to study medicine? There were a number of reasons. Firstly, Emily realised how lucky she had been to have received a solid education. She also loved reading, writing and academia from an early age and was highly curious. “Music is a wonderful outlet for so many of the things I love, but it just wasn’t enough for me,” she explains. “I wanted something where I could use my education and my intellect, to help people in vulnerable positions. “Music is a wonderful way to reach and teach people and it makes people’s lives better. Playing for people and having them go from a good time to a special moment is wonderful. In medicine, you are helping people when they may be at the lowest point in their lives. In that position, little things make a big difference. The idea of being able to do that is a privilege.” Also passionate about education, activism and advocacy, she didn’t know how music could help deliver those things, so went looking for an additional career that could. “The ability to push for change is something I feel strongly about. Medicine is also simply fascinatingly interesting and the human body is a miracle.” Giving up music as a profession was a difficult decision. Playing music all day, every day had been such a big part of Emily’s life. Now as a medical student, she doesn’t feel like she’s lost anything and is a firm believer in the adage that if you want something done, give it to a busy person.
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AUGUST 2022 | 21
Find Cancer Early to close the cancer survival gap. Your postcode shouldn’t determine your cancer outcome, but unfortunately it does for regional Australians, who have lower rates of five-year survival for all cancers combined.
Have you had any of these... ... for more than 4 weeks? Problems peeing
The Find Cancer Early program aims to improve cancer outcomes for regional West Australians over the age of 40 by increasing cancer symptom awareness and encouraging people to visit their doctor, clinic nurse, or Aboriginal health worker earlier. Our recent campaign evaluation found that 70 per cent of 953 regional West Australians surveyed had seen the campaign, and as a result of seeing the campaign 108 people made an appointment with a General Practitioner (GP), while 245 people thought about making an appointment. In Australia, over 75 per cent of cancer cases first present in general practice as a result of symptoms. GPs play a vital role in the early detection of cancer, and regional GP’s especially have the potential to improve cancer survival rates for regional West Australians and close the gap. Our Find Cancer Early Guide for GPs assists GPs in the early diagnosis of prostate, lung, colorectal, breast and skin cancers. This guide employs evidence-based positive predictive value (PPV) tables that highlight the clinical features that best predict cancer. We recommend regional GPs download or print off our Find Cancer Early Guide for GPs at findcancerearly.com.au/gp/ and get into the habit of referring to it for guidance when patients report symptoms. For more information and other resources, visit the Find Cancer Early website findcancerearly.com.au.
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The earlier cancer is found, the grea ter the chance of successful treatmen t. Partner:
Department of Health
For more information visit findcance rearly.com.au or call 13 11 20 03/2022
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Music and medicine in perfect harmony continued from Page 21 “While I can’t practise seven hours a day, I can still practise one to two hours a day and I still have almost as many concerts as I did before. If something’s important to you, you make time for it.
Harmonising interests “If anything, I think studying medicine has improved my playing. I play because I love it, not because I have to do it as my career, or to jump through hoops. To be able to play what I want to play, and for the sheer pleasure of it, gives me such joy. “I am the luckiest person alive. What more could I ask for?” Around her studies Emily remains a stickler for lengthy daily practice and she also performs with a number of local groups, including the Fremantle Chamber Orchestra, usually as a soloist. One of those groups is the WA Doctors’ Orchestra, who come together every so often for charity concerts. Featuring medical doctors, medical students and allied health workers, the musicians span five decades in age. With proceeds going to Breast Cancer Care WA, their concert on August 21 features Emily as a soloist playing Tchaikovsky’s Violin Concerto. The other two pieces being performed are the overture of The Barber of Seville and Brahms Symphony No. 1. “In my ideal world, I’m not just a violinist, I try to be an actor on stage. As an audience member, I don’t just want to see someone on stage, I want to be totally possessed by them. “The artist I admire the most is Rudolf Nureyev because when you see him, you can’t take your eyes off him. Every second he is living the part he’s dancing. That’s my dream as a musician, to be able to become what you play. It also means you can become so many things in your life. You can become characters who are so very different from your own and live that little bit of fantasy.” These days, classical music still makes up the bulk of Emily’s MEDICAL FORUM | CANCER CARE
listening but she also loves jazz. She has started doing some jazz arrangements because she loves the freedom of the style, choosing either violin or the piano, depending on her mood. Emily also loves to draw and for the past 18 months has been working on a children’s picture book about the fast-dwindling colony of Little Penguins on WA’s Penguin Island.
Research focus With the disclaimer that two years ago she wanted to be a professional violinist, at medical school Emily’s current interests are in haematology and oncology because she has been enjoying the mix of research and patient contact. She recently received a scholarship from the Royal College of Pathologists of Australasia for a research project on chronic myeloid leukemia. Watching the speed of change when it comes to treatment and diagnosis for various conditions is one of the aspects Emily finds exciting about medicine. “It gives you so much hope for what can be done.”
to understand how to sing musical scales. Preferring books to television – though she does like the odd silly old BBC show – Emily is a dedicated bookworm and you’ll easily find classic literature (she’s currently in a Shakespearean phase) alongside university tomes. “When you read Shakespeare at the same time as books on human psychology, you realise how much he knew about people, it’s quite extraordinary.”
WA Doctors’ Orchestra Charity Concert 2022 is on Sunday, August 21 at 2pm at St Hilda’s Anglican School for Girls in Mosman Park. Tickets from www.trybooking.com/ CACSB
At home she has found herself caretaker for a vocal extended family of frogs which live in her garden and like to croak away at all hours. Rudely, they don’t seem AUGUST 2022 | 23
At SKG, we care about your patient’s welfare
Now bulk billing. Visit skg.com.au for full details, some exceptions do apply. 24 | AUGUST 2022
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When doctors say no to abortion With some WA doctors refusing to provide referrals for women seeking abortions, Curtin University researcher Meagan Roberts argues what needs to change. The recent US Supreme Court ruling to overturn Roe vs Wade is an important opportunity to reflect on the current status of abortion laws and reproductive rights here in Australia.
GP. This includes reports of clients “doctor shopping” where they were seeing multiple GPs before finding one who would provide a referral. This finding is congruent with findings from a NSW study, where one participant reported visiting five different GPs before obtaining a referral.
Numerous barriers to abortion access still remain and there is wide variability in the way it is regulated nationwide. Recent advocacy efforts are being made to protect the legal and reproductive rights of all people in Australia. One critical barrier commonly faced is difficulty obtaining a referral for the procedure. This process of ‘referral denial’ was explored in a recent study in WA. GPs and other health professionals play a fundamental role in providing support during what can be a challenging time to ensure patients make safe and informed decisions. The denial of sexual and reproductive health care by health professionals has been dubbed by some as a worrisome and growing global trend. Often termed conscientious objection, this issue refers to the refusal of services such as provision of the emergency contraceptive pill, sterilisation, infertility treatments and termination of pregnancy due to ethical, religious or other beliefs. Despite occurring in other areas of reproductive health care, conscientious objection appears most prevalent in the refusal to provide or refer for abortion services.
Current WA law Policies and legislation governing access to termination of pregnancy services vary across states and territories. This “postcode lottery” means that abortion is still not a guaranteed right for women, and is dependent on where they live. WA operates under slightly different legislation whereby a referral from
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Staff perspective
a medical practitioner is needed for a person to be eligible for a termination. This means that two separate doctors need to be involved in the process – a referring doctor and a termination provider. Timely and efficient access to termination services in WA is also dependent on the capacity of an individual GP or health service to meet patient needs, and the existence of effective referral pathways. Technically, GPs in WA have no legal obligation to participate in a consultation or provide referrals for termination services. Several international studies have reported the incidence and impact of termination service and referral denial. However, there is a lack of evidence in a local context.
Referral denial exists A recent study exploring the impact and experiences of termination referral denial from the perspective of service providers in WA found that it exists and can have profound impacts on both clients and staff. Participants in this study were staff employed at a clinic offering medical or surgical termination services. All participants reported that at some point in their current place of employment, clients had reported to them that they had been denied a referral for a termination by a
Staff working at termination clinics in Perth spoke about the impact they saw termination referral denial had on their clients, and how the process of attempting to obtain a referral would often leave clients feelings distressed when they finally reached their clinic and spoke about their experiences. “Sometimes a girl will say to me, I found it so difficult. She's come with her referral, but she'll say, ‘I found it so difficult, I had two or three doctors completely refuse to give me a referral.” Staff said this denial could add to the trauma of an already difficult and physical and emotional situation. Several staff members felt angry and frustrated by their clients’ experiences, speaking passionately about abortion being an essential health service – access to which should not be denied by anyone. This view is shared by those advocating for reproductive rights in Australia following the overturning of Roe vs Wade and the threat of a rise in negative public attitudes labelling abortion as “bad”. This study shows that termination referral denial limits the capacity of the health system in WA to provide accessible abortion services. The two doctor sign-off for an abortion has also been cited as being unnecessary from a medical perspective. continued on Page 27
AUGUST 2022 | 25
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Lifting our game for stroke patients Access to specialist hospital services is crucial for stroke patients, write Professor Bernard Yan and Kelvin Hill. Access to a dedicated hospital stroke unit makes the biggest difference to outcomes in patients who present with stroke. However, currently, not all Australians have such access. If we want to improve the way people receive the best treatment for stroke, this needs to change. The Australian Stroke Coalition (co-founded by Stroke Society of Australasia and Stroke Foundation) characterise a stroke unit as a facility in which medical, nursing and allied health professionals with expertise in stroke provide coordinated care in a geographically co-located environment. Provision of these services differ from state to state and depend on the budget priorities of each hospital and state government. Having a robust way of recognising which hospitals have the essential elements of stroke unit care is an important first step to ensure the quality of care and patient outcomes, but the information can also be used to positively influence the whole system.
Results from the Stroke Foundation’s 2021 national acute services audit show that not all Australian hospitals are meeting the requirements outlined in the Australian Stroke Services Framework and Acute Stroke Care standards. While more than 80% of patients who had been in dedicated stroke units left hospital with a comprehensive discharge plan, of those who did not receive their care in a specialised unit only 62% were discharged with bespoke recovery advice. We believe that meeting agreed national standards is an important step in ensuring all Australians receive the same level of care, regardless of where they live. That is why the Australian Stroke Coalition, which is co-chaired by Stroke Foundation and the Stroke Society of Australasia and includes representatives of those working in the field, is launching a pilot project to implement a certification scheme for stroke units. Participation will be voluntary. Our aim is to develop a certification
scheme which hospitals with stroke units can agree to participate. The spirit of the scheme arises from the collective will to lift our game. We want to emphasise that this is never about penalising the services which currently fall short. We are recruiting a part-time senior project officer who will coordinate the project over the next 12 months. When we roll it out to stroke units, there will be clear guidance on participation and the expected impacts and outcomes. In the past 25 years the way stroke is treated has evolved substantially, but we can always do better. We can save more lives, and we can ensure survivors of stroke have even better outcomes. Almost 30,000 people experience stroke each year. We want to work with Australian stroke units to ensure they have the processes in place and the appropriate resourcing to deliver the optimal level of care to patients. ED: Professor Bernard Yan is president of the Stroke Society of Australasia and Kelvin Hill is national manager of clinical services with the Stroke Foundation.
When doctors say no to abortion continued from Page 25
WA reform With legislative reform being a long-term advocacy goal, the recommendations from this study seek to minimise the potential negative impact and experiences of WA abortion legislation and conscientious objection. Recommendations include: • Advocate for mandatory ‘on MEDICAL FORUM | CANCER CARE
referral’ policies that require GPs who are conscientious objectors to be legally obligated to onrefer patients to an alternative GP or service. This law currently exists in Victoria, by requiring any objecting GP to refer the client to a health professional who does not have any conscientious objections to termination • Provide a publicly available list of termination referral options to assist in facilitating accessible patient pathways
• Promote comprehensive GP and community education on abortion procedures and legislation • Encourage more GPs to become prescribers of medical termination of pregnancy, as only 10% of Australian GPs are registered as providers. ED: Meagan Roberts is a research assistant at the Curtin School of Population Health, and Dr Jacqui Hendriks is a contributing author.
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28 | AUGUST 2022 42 | SEPTEMBER 2020
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Does sleep ward off dementia? As more is understood about how sleep affects our brain health, GPs are often the first port of call for worried people, explains researcher Dr Camilla Hoyos. Growing evidence suggests disturbed sleep may increase the risk of developing dementia. Sleep optimises the ability of our brains to stabilise and consolidate newly learned information and memories. These processes can occur across all the different stages of sleep, with deep sleep (also known as Stage 3 or restorative sleep) playing a key role. Furthermore, it is now known that the glymphatic system or the waste system of the brain is highly active during sleep, especially during deep sleep. This allows for waste products in our brains, including toxins, that have built up during the day to be cleaned out. Toxins in the brain include betaamyloid, one of the key proteins in the development of Alzheimer’s disease. Disturbing sleep could disrupt this cleansing process and lead to an accumulation of betaamyloid in the brain. The important role of sleep in these vital processes has led to the investigation of whether sleep disruption, including sleep disorders such as sleep apnoea, could be associated with changes in our cognition when we age and a possible link to the development of dementia.
Sleep apnoea is a common condition, estimated to affect one billion people worldwide. Sleep apnoea causes the upper airway to close either completely (an apnoea) or partially (a hypopnoea) during sleep. These closures or obstructions can range from 10 seconds up to one minute and can lead to a drop in blood oxygen levels. To start breathing again, a short awakening occurs without the individual living with sleep apnoea being aware.
These closures may lead to drops in blood oxygen levels and fragmented sleep. The disruptions could impact the important processes in maintaining our brain health that occur during sleep. Studies have shown sleep apnoea to be associated with a 26% increase in the development of cognitive impairment, as well as greater amounts of beta-amyloid in the brain. However, it is not clear if treating sleep apnoea can reduce this risk.
New COVID kids’ jab Doctors have welcomed the approval of a COVID-19 vaccine for children as young as six months old.
Advisory Group on Immunisation is expected to provide advice to the Government.
The Therapeutic Goods Administration has provisionally approved the Moderna vaccine for use in children aged six months to five years for the next two years.
Professor Paul Griffin, director of Infectious Diseases at Mater Health Services and Associate Professor of Medicine at the University of Queensland, said the approval was based on clinical trial data from over 6000 children in this age group in the US and Canada.
The use of the vaccine in the national COVID-19 vaccination program is still to be determined and the Australian Technical 30 | AUGUST 2022
“Data generated from this trial
demonstrated a favourable safety profile and an immune response similar to that seen in young adults,” Professor Griffin said. “While rates of more significant disease are fortunately relatively less in this group, having an option to be able to protect those who want to be protected, or perhaps have an increased risk for whatever reason, is another positive step forward.”
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There are several treatments for sleep apnoea. The gold-standard is continuous positive airway pressure therapy (CPAP), where a mask connected to a pump blows continuous air down the upper airway keeping it open. It is not known whether treating sleep apnoea will reduce the risk of dementia. Our recently published study aimed to understand if treating older adults with both sleep apnoea and mild cognitive impairment could improve thinking and memory skills in the short term. The trial assessed the effect of CPAP treatment on memory and thinking skills compared to no treatment. This was a cross-over study, which means all participants had both CPAP and no treatment during the trial. Participants were randomised to the order in which they completed the two arms, meaning this process was done by chance and everyone had the same probability of using CPAP first. Participants were seen by trained staff to get established using the therapy. After using the treatment for three months,
participants underwent a series of cognitive tests, and waited two weeks before starting the other study arm. The researchers found that compared to not treating sleep apnoea, thinking skills were not improved with CPAP, whereas some improvements in memory were observed. This suggests treating sleep apnoea could potentially improve outcomes in the short term, but it is unknown if it would have any impact on long-term cognitive decline. Mild cognitive impairment is the stage between the expected cognitive decline of normal ageing and the more serious decline of dementia. In mild cognitive impairment, cognitive changes are noticed by the individual and their family and friends, but the individual is still able to successfully carry out everyday activities. Mild cognitive impairment is associated with an increased risk of developing dementia in subsequent years. Researchers believe this is the optimal time to intervene in an attempt to prevent a future dementia diagnosis.
This is where the role of the GP can be most useful. General practitioners may be best placed to observe early changes in cognition, especially if they have been seeing a patient for many years. As GPs are already involved in assessing and managing people with other chronic diseases including asthma and diabetes, it would be beneficial if they were armed with greater information about sleep apnoea, namely how to identify and manage it, in collaboration with sleep specialists. A previous study suggested CPAP could slow cognitive changes over one year in older adults with mild cognitive impairment and sleep apnoea. However, studies of longer duration are needed before we can say what the long-term effects look like. This is a space to watch for GPs, with further insights into the relationship between sleep and cognitive decline expected in the coming years. ED: Dr Hoyos is a sleep researcher based at the Woolcock Institute for Medical Research.
BreastScreen WA opens a new screening and assessment clinic in Joondalup BreastScreen WA has opened a new permanent screening and assessment clinic in Joondalup at 57 Joondalup Drive. This clinic will give women in the northern suburbs year around increased access to screening mammograms and work-up assessment. The clinic has free parking, easy access to public transport and facilities for women with disabilities. The Joondalup clinic will replace the existing Wanneroo clinic, which will close when the lease ends in October. All asymptomatic women aged 40 years and over are encouraged to have a free screening mammogram every two years.
Women may book online www.breastscreen.health.wa.gov.au or phone 13 20 50 Medical Forum_Joondalup 2022.indd 1
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26/05/2022 1:56:47 PM
AUGUST 2022 | 31
Where we live. How we live. What we’ve lived.
Trans is an umbrella term that describes gender identities which differ from one’s sex as registered at birth. This difference can cause significant distress and psychosocial impairment, known as gender dysphoria. In order to alleviate this distress, trans people might seek to have their gender affirmed socially through the use of a name and/or pronouns which better reflect their affirmed gender. Ransomware, in particular, is a huge concern for the medical industry. These malicious types of software are designed to block access to a computer system until a specific amount of money is paid. Since any downtime can put lives at stake, practices may choose to pay the ransom and move on as quickly as possible. By paying the ransom, medical businesses might also believe they’re protecting sensitive data from being exposed or lost forever, which makes sense when you consider the huge amount of valuable personally identifiable information (PII) used in the industry. Paying a ransom is often seen as a simple business decision: if the costs to recover from a ransomware attack exceed the ransom payment, some may choose to pay the ransom amount. Some medical practices will also choose to quietly pay a ransom rather than report it to officials and risk reputational damage.
Paying may not work Paying the ransom to regain access doesn’t completely eradicate the risks. Hackers could easily install other types of malware that could be activated later in order to launch new attacks. Victims might even suffer repeat attacks if other criminal groups learned that they made a ransom payment.
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Why pronouns matter Using the correct pronouns for trans patients in primary care is important. Blake Cavve and Xander Bickendorf review the evidence and explain why. Trans is an umbrella term that describes gender identities which differ from one’s sex as registered at birth. This difference can cause significant distress and psychosocial impairment, known as gender dysphoria. In order to alleviate this distress, trans people might seek to have their gender affirmed socially through the use of a name and/or pronouns which better reflect their affirmed gender. In English, the pronouns we use often indicate that person’s gender, most commonly he/him/his or she/her/hers. Some people may prefer neutral or other pronouns, commonly they/them/theirs. Some trans people will request gender-affirming medical intervention to help their body align with their experienced gender. General practitioners are often the first point of contact for trans people seeking medical intervention or psychological support. Additionally, while some people may seek a GP referral to specialist endocrinology or sexual health care, GPs commonly prescribe and monitor gender-affirming hormone treatments. Overall, GPs are the most common service for young trans Australians to access regarding their gender identity. Trans people may also have elevated need for other forms of medical care. Mental health care is a particularly important ongoing factor to consider for trans patients. Trans people have elevated rates of depression and anxiety, and 80% of young trans Australians have a history of deliberate self-harm, with one in two having attempted suicide in the past – a rate 20 times higher than adolescents and young adults in the general population. Similar rates have been found for trans adults. MEDICAL FORUM | CANCER CARE
Similarly, 61% of Australian trans youth have experienced feeling isolated from health services (of which GPs were the key provider) and these individuals have higher rates of self-harm and suicidal thoughts than those who did not experience this isolation.
Discrimination and victimisation contribute to these higher rates of mental health difficulties. However, health care for trans people is not always about gender-affirming needs; trans people also sprain their ankles and have vaccinations! While providing sensitive and individualised treatment for general health care needs may require knowledge of someone’s trans status and consideration of gender dysphoria in planning care (e.g. preparing for and coping with transvaginal ultrasounds or cervical screens in trans masculine patients), doctors should avoid asking intrusive questions (e.g. about genitals or surgical procedures) unless relevant to the patient’s current care concerns.
Barriers to care Many trans people report significant barriers to accessing health care, including primary care, through being misgendered (e.g. using the incorrect name and pronouns), feeling humiliated or unsafe, and, in some cases, being refused care. Australian trans adults largely receive sexual health care from a GP clinic (72.3%), however, fewer than 50% feel their GP provides care sensitive to their needs, and fewer than 30% feel that their GP intake form allows them to properly describe their gender identity (including name and pronouns).
Negative experiences with primary care, such as incorrectly gendering patients and using the wrong name or pronouns, can lead to hesitation towards accessing future medical care, leading to preventable illnesses and contributing to poor mental health. Personal testimony: “Regular and routine visits to a trusted GP don’t happen for me, instead I’m scrambling for a once-off option when I’m truly unwell or joining considerable waitlists in search of care that is more inclusive. I feel this affects my ability to maintain good health and access timely preventative care.”
Pronouns matter The use of chosen names and pronouns is associated with improved mental health and a sense of wellbeing for trans people. Trans patients who feel more comfortable with, and respected by, GPs also have better mental health. A number of medical and psychological organisations therefore recommend use of patients’ chosen names to be integrated into clinical care. The RACGP Standards for General Practices (5th edition) advice also recommends collecting information about birth-registered sex, gender and pronouns. By using the correct name and pronouns for trans patients, you are helping to support their mental health and helping to establish a relationship of respect and trust.
continued on Page 34
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“We’re worried about you” A simple comment can pack an emotional punch, especially for people who smoke, write Melissa Ledger and Sarah Beasley. Cancer Council WA has been leading anti-smoking public education activities for more than 20 years through its Make Smoking History Program. Our latest TV commercial, Worried About You, is the 14th WA-made TV commercial and is central to our latest public education campaign. Make Smoking History began in 2000 under the name ‘Target 15’ at a time when smoking rates in WA were 22.5%. We soon changed our name to reflect the breadth of our tobacco control work. Twenty-two years later and coupled with a longterm commitment from our funding partners WA Health and Heathway, we have delivered 58 bursts of campaign activity. Some might wonder why we are still making anti-smoking campaigns with current smoking rates in WA hovering around 10%. Isn’t the job done? Tobacco is still the number one cause of preventable death and disease in Australia. In 2018-19,
close to $127 million was spent on treating tobacco-caused diseases in WA hospitals, and there were about 13,000 hospitalisations attributable to tobacco. Anti-smoking campaigns have played a pivotal role in the significant decline in smoking rates in WA. They work on multiple levels as part of a comprehensive approach to tobacco control, prompting quit attempts, encouraging people to stay smokefree and preventing young people from starting. Critically, when campaign funding is removed or reduced, you can expect declining smoking rates to plateau or even increase. We know our campaigns can also generate community support for smoke-free policies and regulations. Our latest campaign is a departure from previous campaigns such as 16 Cancers and Voice Box, which used graphic imagery to highlight negative health consequences of smoking to prompt quit attempts. The research is clear on the efficacy
of campaigns depicting hardhitting health harms, but different messages work for different people. Worried About You portrays a father/daughter narrative that aims to prompt people who smoke to think about how their habit is emotionally affecting the most important people in their worlds. When talking to people who smoke in our formative research, it was clear that concerned loved ones was a pressure point that could motivate quit attempts. Many people who smoke can relate to being asked by their children why they smoke and when they are going to quit. Children worry about what will happen if their loved ones become ill or die early because of tobacco. They know about the harms of smoking from school and seeing our ads on television. While some people may not be worried about the health impacts of smoking for themselves, no one wants to cause their loved ones distress, which is why it is a powerful motivator to quit smoking.
Why pronouns matter
What GPs can do
health care providers to develop positive relationships in which trans patients: • feel they can be honest and do not have to withhold their trans status in order to receive care • trust their information will be treated confidentially (e.g. that their trans status will not be shared inappropriately) • feel they are safe, respected, and not judged.
As many trans people require regular and long-term medical services, the GP-patient relationship is important to a vast array of health outcomes. Providing inclusive care is key for
In order to provide this sensitive care, it is important that health care providers collect accurate information on trans status, preferred names and pronouns.
continued from Page 33 Personal testimony: “There’s an enormous relief in knowing from the outset that your identity will be respected and that is reflected in how openly I interact with a care provider. It’s very hard to establish trust without having that acceptance.”
34 | AUGUST 2022
Because we can’t always tell someone’s gender just by looking at them, the best way to know which pronouns to use for someone is to ask them. It is important to ask everyone, and not just people who “look trans”. Standard protocols, including a correctly worded question on gender identity, results in patients being more open about their gender identity, and provides the practice with more accurate information. Personal testimony: “If I can’t selfidentify when filling in my medical information, or there is no indication MEDICAL FORUM | CANCER CARE
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HE WORRIES THIS MIGHT HAPPEN TO YOU
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excluded or die early because of tobacco. This is why, in addition to campaigns, part of our team works directly with community, health and corrective services to address smoking in their organisations. Part of our team also works in policy and research to influence top-down strategies, such as reducing the supply of tobacco. For our anti-smoking work to be most effective, we will continue to bring ads to TV, radio, digital and other media platforms as they underpin a comprehensive state-wide program to address these many aspects of Make Smoking History.
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makesmokinghistory.tips
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Knowing this would be a campaign that would pull at the heartstrings, we conducted careful testing on this new concept to ensure it was perceived as realistic and relevant. We also wanted to convey empathy and encourage people who have tried quitting many times before that they too can quit. As we improved each version of the ad, people increasingly took notice of the end voice-over “Quitting’s hard, that’s why we’ve put all the best tips in one place.” People appreciated the acknowledgement that quitting is hard, and found this line to be genuine, empathetic, hopeful and motivating.
that people like me are welcome, I will assume the worst, edit myself and won’t engage honestly with the provider … I feel disempowered.” For sample intake form questions, see the RACGP Standards for General Practices (5th edition) fact sheet. Online e-training for primary care teams are available via the Australian Professional Association for Trans Health or Gender Identity Research and Education Society. ACON’s TransHub also has resources for clinicians and affirming waiting room posters. Recently published best practice guidelines for LGBTQA+ young people include recommendations on creating an affirming and inclusive environment for LGBTQA+ youth, as well as a specific section MEDICAL FORUM | CANCER CARE
Department of Health
At a population level, we can quote the cost of smoking to the health system, hospitalisations, QALYs, lost productivity, the list is long. But at an individual level, the less income you earn, the more likely you are to smoke. This means that cigarettes are taking up more of your pay cheque, and you may find yourself in financial distress. Since stress is a trigger to smoke, this cycle can be hard to break. If you then become ill from smoking and can’t work, it is going to become that much harder to make ends meet.
If you know someone who wants to quit, go to www. makesmokinghistory.org.au/tips. Receiving personalised support from a Quitline counsellor is another avenue that will increase a person’s chances of quitting for good. ED: Melissa Ledger is the cancer prevention and research director with Cancer Council WA, and Sarah Beasley is the Make Smoking History campaign senior coordinator.
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We strongly believe nobody should live in poverty, be socially
on considerations for trans young people.
Key messages • Collect self-identified gender, birth registered sex, legal name, chosen name, and pronouns at intake, and ensure that these are reflected on the medical record. • Consistently call people by their chosen name and pronouns • When you make a mistake, apologise briefly, correct yourself, and keep trying • Train your practice staff (and students) to do the same, regardless of their job within the practice • Take a respectful history obtaining informed consent to physical examination
minimising trauma from physical examination and investigations • Use correct name and pronouns when you are talking about the person in their absence, as well as when they are present • Use date of birth and address as the additional points of identification – don’t say the person’s legal name • Continue to learn more about gender-friendly and traumainformed primary care. ED: Blake Cavve is from the University of WA and Xander Bickendorf is from Telethon Kids Institute.
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Doctor suicide a present danger No medic is an island, says obstetrician Dr Katrina Calvert. In 1623, the then Dean of St Paul’s Cathedral in London wrote a series of meditations, one of which has passed through the filter of time to be recognised as a fragment of poetry. John Donne’s idiom, ‘No man is an island’ is as recognisable as the phrase which closes the same passage: ‘Any man’s death diminishes me, because I am involved in mankind. Therefore, never send to know for whom the bell tolls; it tolls for thee.’ When the bell tolls for any member of the medical community we are all impacted – never more so than when the death of a doctor is through suicide. Physician suicide is a well-
recognised but poorly understood phenomenon. Doctors frequently demonstrate factors which, in the general population, would be protective against suicide, such as high socioeconomic status, high income and postgraduate levels of education.
support services for medical staff can be patchy, and, where present, are often not well accessed, fatigue, burnout and mental health problems are common but remain stigmatised in some areas of medicine, and not enough doctors or medical students have a regular GP.
Despite these protective factors, suicide rates amongst doctors remain higher than the general population and are thought to be rising.
Doctors also have access to medical means to commit suicide, potentially increasing the risk of an attempt and the chances of that attempt succeeding. As regards physician suicide, the most ‘at risk’ groups in our profession are those facing regulatory enquiries, those with a background of chronic, severe, or undertreated mental ill-health, and those exposed to critical and distressing clinical incidents.
The 2017 National Forum on Reducing the Risk of Suicide in the Medical Profession outlined several reasons why this may be so. Doctors and medical students are confronted with, and required to normalise, traumatic events,
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GUEST COLUMN In recognition of the impact of mental ill-health, chronic trauma, and suicide on the medical profession, a framework for action was proposed in 2020 – Every Doctor, Every Setting. The framework outlines five pillars with specific actions to be taken at national, local and organisational level around implementing support for doctors. A key part of this discussion, included in the Tertiary Prevention sub-theme of the framework, is the implementation of effective responses following a physician suicide. These responses must include: Reaching out to family or next of kin Particularly in the context of suicide occurring around critical clinical events, there may be a reluctance on the part of health care co-workers to reach out to the family for fear of provoking anger or blame. This can create a narrative whereby the sum of the accomplishments of a medical practitioner is negated by events around their death, robbing the family of the chance to celebrate
what may have been a lifetime of commitment and positive contribution.
clinical tasks, to allow all staff members to process grief and minimise distress where possible.
Covering admin and rosters
Making long-term plans
These may be obvious, such as acute care shifts that require cover, but there may also be patient results to check, clinic letters to sign, and email accounts to close.
Anniversaries can be difficult, as can significant events, such as the graduation of a group of trainees who have lost a member to suicide. Care and compassion around such events are essential.
Offering support to staff Senior staff will need guidance as to how best to share the information of the death, and what information to share. Sensitivity and compassion will need to be balanced with confidentiality and clarity of communication. This may involve liaison with the next of kin to decide what information should be provided and what withheld. Staff members may wish to attend a funeral, and this needs to align with the wishes of the family. Staff wishing to attend will need their rosters covering and appropriate leave organising – this should be centrally coordinated. Consideration may need to be given to the reallocation or redistribution of clinical and non-
No man is an island, every man is a piece of the continent, a part of the main. The continent of medical practitioners crosses geographical boundaries and is not limited by borders nor by time. The loss of any member of the medical community to suicide is a tragedy that actively, intensely, diminishes us all. As a community we must come together to support each other when these tragedies occur, and we must collectively vow to do everything we can to prevent them in the future. ED: Dr Calvert is a committee member of the Doctors’ Health Advisory Service WA, director of postgraduate medication education at KEMH.
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OPINION BACK TO CONTENTS
Dr Joe Kosterich | Clinical Editor
Room for optimism President Nixon in 1971 called for a cure to be found for cancer by the United States’ bicentenary year of 1976. History shows that 50 years on, we have not cured cancer. In fact, international projections are for an increase in cases over the next few decades. Part of this reflects an ageing society.
Progress in medicine generally goes in fits and starts rather than a smooth progression. Advances can come when least expected. On that basis, I remain an optimist.
But it is far from all bad news. Survival rates for breast and bowel cancer to name but two have increased. This is due to a combination of improved prevention strategies, early detection and better treatments. It is claimed in some circles that some cancers can now be seen as a chronic disease. That said, pancreatic and lung cancer continue to have low five-year survival rates. AIHW data from 2020 shows lung cancer to be the third leading cause of death in males (4751) and fourth in females (3706). This is higher than breast and prostate cancer respectively. Coronary heart disease remains the number one cause of death in males and second in females. Smoking is the chief risk factor. Improvements in cancer care start with research and this month we have articles which explore the journey from clinical trials through to evolving treatments. Irritable bladder, perinatal mental health and the importance of exercise in an older age group are also covered. Two issues get little air play. First is the number of people who missed out on cancer testing and treatments due to lockdowns and cancellations of surgery and other treatments. This number will likely never be known as it will be buried in total cancer statistics. The other is the flatlining in Australian smoking rates. Despite the highest per stick price in the world (rising again on September 1), smoking rates have barely moved since 2013. Amongst indigenous populations the rate is around 40% which is treble that of the general population. The black market is thriving. In the 1980s, Australia led the world. Today, countries such as the UK, Japan and New Zealand have sailed past us by adopting innovative approaches to helping smokers quit. Here, for reasons unclear to me, resting on our laurels and doing more of the same remains the preferred option. Progress in medicine generally goes in fits and starts rather than a smooth progression. Advances can come when least expected. On that basis, I remain an optimist.
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Conception, gestation, delivery – how new cancer therapies reach patients By Adj. Associate Professor Tim Clay, Medical Oncologist, Subiaco For many, the first thoughts of cancer treatment are chemotherapy and its attendant toxicities. We are not yet free from these therapies although the therapeutic armamentarium in the ‘war on cancer’ has expanded rapidly. Many advanced cancers are now thought of as chronic conditions, and for some cancers we even speak in hushed tones about potential cure. Melanoma and Non-Small Cell Lung Cancer are the current poster children in the seismic shift in survival outcomes. Malignant haematology and medical oncology remain heavily dependent on the development of systemic anticancer therapies. Trials are essential to improving care and outcomes in a rigorous and reproducible fashion before reaching the clinic.
Gestation – clinical development Therapies that advance to clinical development undergo a number of phases of clinical trial. Each study undergoes rigorous ethical review prior to commencement with participant safety at the forefront of ethical review. Activities in the study must adhere to the defined trial protocol
Cancer treatments are evolving rapidly Clinical trials are to establish safety and efficacy Trials are not just the domain of big pharma.
Umbrella Trial – Phase 2 Biomarker 1
Treatment A
Biomarker 2
Treatment B
Biomarker 3
Treatment C
No Biomarker
Treatment D
Shared Biomarker / Target
Single Treatment
Single Tumour Type
Conception – preclinical development A detailed understanding of cancer biology is essential for any new cancer therapy. Laboratory research interrogates cancer models developed from previously donated cancer samples. Potential therapies are tested both in cell lines and in small animal models to determine which show potential for further development.
Key messages
Basket Trial – Phase 2
Condition 1
Promising therapeutic strategies undergo further preclinical testing to attempt to predict their behaviour when applied to people in later studies. Species are picked which best approximate future human subjects to predict drug metabolism and potential toxicities.
Condition 2
Condition 3
Phase 1 Dose Escalation
Dose Level 1
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Dose Level 2
Dose Level 3
Continue until Dose Limiting Toxicity Found or Maximum Effect Reach
Maximum Tolerated / Required Dose
Expansion and Phase 2 Dose
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CLINICAL UPDATE
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CLINICAL UPDATE Randomised Trial – open label – Phase 2 or 3 – can have more than two arms Standard of Care Condition of Interest
Randomisation Experimental Arm
Randomised Trial – Placebo Controlled – Phase 2 or 3 - can have more than two arms Standard of Care + Placebo (Blinded) Condition of Interest
Randomisation Standard of Care + Experimental Therapy (Blinded)
Crossover Design – comparison of toxicity or patient preference
Condition of Interest
(documents ranging between 20 to 200 pages). Consent forms outline the reasons for a study, its risks, benefits, and burdens, and whether the study is blinded or involves a placebo control. Consent forms can be confronting, lengthy and complex for research participants to navigate but come with explanations from study investigators. Inclusion and exclusion criteria are used to define the population of interest. Phase one trials were traditionally the domain of testing drug safety, but their role is expanding. Testing of new drugs or new drug combinations is cautious and undertaken with close attention to both anticipated and unanticipated toxicities. Drug doses start low and are escalated until biological saturation of the intended target pathway or until significant dose limiting toxicities are found. A recommended phase two dose is then assigned. Phase two trials are larger studies enrolling 50-200 patients. These studies are designed to be a modest test of efficacy. Novel study designs including basket studies and umbrella studies are being used to improve efficient trial conduct while reducing costs. MEDICAL FORUM | CANCER CARE
Treatment A
Washout Period
Treatment B
Treatment B
Washout Period
Treatment A
Randomisation
Phase three trials aim to affirm or alter the standard of care by comparing it to experimental treatment(s). These studies are large and recruit hundreds or thousands of patients with randomisation used to reduce bias. Statistical projections inform the number of study subjects required to answer the question. Studies can be designed to show superiority (new treatment is better) or noninferiority (one treatment as good as another). Many studies also collect patient reported outcomes (PROs) – these are validated questionnaires to gauge the impact of treatments and their toxicities on trial participants. New cancer therapies must deliver the same or better quality of life outcomes. Translational research (bedside to bench) also helps to determine which patients derive the greatest benefit.
Delivery – getting drug to patient
research and reward shareholders. In deciding what to fund, the PBS considers the health economics of a new therapy. While we wait for new therapies to be listed, cancer specialists attempt to find other ways to treatment. This may be a clinical trial or a compassionate access scheme. The most vexed approach is self-funding as financial toxicity to the patient can be significant and run into tens of thousands of dollars. Despite the challenges of clinical trials, they are a very rewarding aspect of cancer care. They are central to the drive to develop new therapies to improve patient outcomes. They are not just the domain of “big pharma” with many Australian-led cooperative groups developing and testing treatment ideas. Like many of my fellow clinicians I feel fortunate to be practising in this speciality at a time of rapid improvements in cancer care and patient outcomes. Author competing interests- nil
The explosion in new therapies presents a daunting problem for society. The cost of developing and commercialising a new treatment can run into the hundreds of millions of dollars – companies seek to recoup study costs, fund further AUGUST 2022 | 41
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The evolution of geriatric oncology By Dr Azim Khan, Medical Oncologist, Hollywood There is an increasing number of older adults with cancer. From 2010 to 2030 cancer is expected to increase by 45%, with a 67% increase among older adults. Currently 70% of cancer mortality occurs in people over 65 years. Fortunately, there have been significant advances in the evolution of geriatric oncology cancer management. ‘Older adults’ or ‘the elderly’ is a subjective cultural concept, varying from culture to culture, depending on social, health-related, and economic factors. In Western societies, 65 or 70 is a standard cutoff point to define the elderly. However, functional, and chronological age can differ vastly from person to person. The functional age in geriatric oncology determines management and considerable effort is committed to accurately evaluating and maintaining functionality during treatment. The age cut-off exists to encourage awareness, not to ascertain oncological management. Ageing leads to a decline in organ function. During physiologically challenging times (e.g., cytotoxic therapy), functional reserve is essential, and any limitations may be exposed. The result equals increased risk of acute illness and complications during cancer treatment. Geriatric oncology emphasises identifying and assessing geriatric syndromes including frailty. This denotes a multidimensional syndrome of loss of reserves (energy, physical ability, cognition, health) giving rise to vulnerability. Clinical frailty scores aid in assessing frailty in older adults. A study in 2003 found older adults with cancer have more geriatric syndromes than older adults without cancer. The study also noted that some geriatric syndromes are more common for patients with specific cancers. Quite commonly, ECOG Performance Status (PS) Scale is used by oncology caregivers to access MEDICAL FORUM | CANCER CARE
Key messages Increasing numbers of older adults have cancer Advancing geriatric oncology practice has resulted in the development of multiple tools/ calculators for assessment-guided management Geriatric oncology incorporates the thorough management of older patients with cancer by employing validated assessment tools and comprehensive assessments for improved outcomes. suitability to cytotoxic treatment or targeted treatment, but performance status (ECOG or Karnofsky) lacks reliability as a form of functional evaluation in certain elderly patients. Geriatric oncology practice has led to the development of multiple tools/calculators for assessment, which guide management by providing information on specific cancer types and treatment options for the older population. Comprehensive geriatric assessment (CGA) is the most detailed. CGA is defined as “multidimensional interdisciplinary diagnostic process focused on determining a frail older person’s medical, psychological, and functional capability to develop a coordinated and integrated plan for treatment and long-term follow-up". CGA is classified into domains, with each domain corresponding to one aspect of ageing-related issues. Each domain is evaluated through one or more validated tools (e.g. cognition – mini mental state examination, MMSE), daily activities (Lawson State, Katz Index) and comorbidities (Charles Comorbidity Index). CGA is a detailed form of evaluation and follow-up for elderly patients before and during cancer treatment. It identifies problems that are not identified by routine patient history and physical examination. Patient selection is important in a clinical setting due to time restraints, but brief tools such as G8 (under 14 is
abnormal and correlated with poor Overall Survival) can be used. Geriatric oncology practice has also advanced with the development of validated tools for chemotherapy toxicity prediction. The Cancer and Aging Research Group (CARG) prediction tool assesses chemotherapy toxicity for older patients with cancer. The Moffitt Cancer Centre’s Chemotherapy Risk Assessment Scale for HighAge Patients (CRASH) calculator categorises older patients with cancer into one of four risk areas of severe toxicity from chemotherapy. The advancement of this rapidly growing field is not without backing of RCTs, which recently have shown the benefit of incorporating geriatric principles. The GAIN study showed that baseline geriatric assessment and its management recommendations provided to oncologists prior to commencing treatment reduced clinician-rated grade three to five toxicity over three months. Another Australian RCT found that integrated onco-geriatric care reduced emergency presentations, hospital admissions and lower initial treatment discontinuation. The sub-speciality faces a dilemma as trials have an underrepresentation of older adults. Geriatric patients are underrepresented yet have a high cancer burden. A study found that the geriatric population accounted for only 25% of cancer clinical trial participants, even though over 60% of new cancer cases were diagnosed among older adults. In conclusion, geriatric oncology incorporates thorough management of older patients with cancer by employing validated assessment tools and comprehensive assessment improving outcomes. Geriatric oncology helps predict complications and side effects from chemotherapy and functional decline during treatment along with assisting cancer treatment decisions. – References available on request Author competing interests – nil
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A radiation oncologist’s perspective on advances in lung cancer treatment By Dr Nicholas Bucknell, Radiation Oncologist, Nedlands & Rockingham As a thoracic oncologist, I am often asked at social events, “Why work in lung cancer?” I was naturally drawn to this field having experienced my grandfather dying from mesothelioma. After seeing that terrible disease and its effects, I found in radiation oncology a mix of curative intent and palliative treatments, with the latter improving pain or minimising symptoms for patients with end stage disease. My passion for thoracic oncology was spurred on through inspirational clinicians including Prof Ball who led the CHISEL trial which demonstrated an overall survival (OS) advantage of stereotactic ablative body radiotherapy (SABR) over conventional radiation treatment. By the end of my training, patients were living for years on EGFR and ALK tablet-based targeted therapies, and the importance of specialist lung cancer nurses, allied health support and survivorship care was gaining traction. SABR is an impressive tool for
Key messages SABR is an effective treatment modality for patients with peripheral early-stage lung cancer In more advanced lung cancers, improved systemic therapies have enhanced survival, and advances in radiation technology have reduced toxicities Cancer is now the leading cause of death for Indigenous Australians and the increasing gap needs immediate attention.
treating primary lung cancer and oligometastic disease. For peripheral tumours it is associated with extremely low toxicity and relative preservation of lung function. SABR is convenient for patients. With a treatment time of 30 minutes, delivered in one to four outpatient sessions, I have even had patients go to work half an hour after treatment. As an outpatient procedure, it is less resource intensive, and internationally there was significant increased uptake in SABR during COVID-19.
A single fraction breath-hold SABR treatment plan to a right lower lobe lesion measuring 12mm. Image A demonstrates the location on the tumour relative to the lung and with the 10% of dose in blue, 50% in green. Image B demonstrates an axial image of the SABR plan demonstrating the dose covering the target volume (cyan) with a maximum point dose of 145.5% deposited in the centre of the tumour.
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Techniques have become so refined that we can now treat some primary lung cancer patients with a single fraction. Surgery remains the gold standard treatment for earlystage non-small cell lung cancer (NSCLC), but SABR is an excellent option in patients with poor lung function or other comorbidities. Randomised trials are currently under way to compare the two techniques. In more advanced disease, systemic therapy has driven improvements in survival. The landmark PACIFIC trial was the first trial to show a survival advantage with consolidation immunotherapy versus placebo after chemoradiotherapy in stage III NSCLC. The 2022 updated analysis confirmed statistically significant benefits in OS and progression-free survival (PFS) at five years of 42.9% and 33.1%, respectively. In operable patients, Checkmate 816 has recently published data showing a 37% reduction in recurrence, death, or progression, which has prompted FDA approval for neoadjuvant chemo-immunotherapy. Regardless of the primary treatment modality, there is emerging recognition of the importance of supporting patients to enable treatment course completion. Logically these new medications don’t work unless patients are well enough to receive them. Six weeks of chemo-radiation followed by one year of consolidation immunotherapy is an intensive regime. Minimising toxicity so that patients can complete these treatments has become possible with techniques such as volumetric modulated arc therapy (VMAT). A recent article in the Journal of Thoracic Oncology demonstrated the advances of this technology over conventional treatment. Proton, ultra-high dose rate (FLASH), and functional lung avoidance (FLA) are even more complex techniques on the horizon. continued on Page 46
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De-escalation of surgical management of the axilla in breast cancer By Dr Helen Ballal, Breast Surgeon, Subiaco Management of the draining axillary lymph nodes in breast cancer has thankfully come a long way since the Halsted radical mastectomy. While it is still vital to stage the axilla, as it remains a critical component of prognosis, there is an ongoing trend for surgical deescalation. This is preferable for the patient where possible as traditional axillary dissection/clearance has several significant co-morbid complications including seroma, lymphoedema, chronic pain, axillary paraesthesia and shoulder dysfunction. Axillary lymph node dissection (ALND) was de-escalated to four node axillary sampling in the 1990s and subsequently sentinel node biopsy (SLNB) became standard. SLNB involves injecting a radioactive tracer and/or a blue dye into the lymphatics draining the breast so that the first, ‘sentinel’ lymph nodes of the axilla can be identified. If these nodes are negative, the likelihood of further axillary disease is low. Multiple studies demonstrated a high SLN identification rate, low false negative rates and no difference in overall survival, disease free survival and locoregional recurrence in those omitting ALND. Morbidity associated with SLNB is significantly less than in full ALND.
Initially, SLNB was often accompanied by intra-operative node assessment to allow for completion of ALND at the same operation. Given the number of treatment options for a positive sentinel node, there has been a
move towards allowing discussion at MDT with full histopathology. Axillary radiation has been shown to have good control with fewer complications than dissection in low-volume disease, and for certain patients with limited nodal
Advances in lung cancer treatment continued from Page 45 The outlook has also improved for patients with small cell lung cancer (SCLC) where survival has traditionally been poor. In the CONVERT trial, the 30-month median survival in the control arm is the best recorded 46 | AUGUST 2022
survival for limited stage SCLC. In patients with more extensive stage disease, the introduction of new systemic agents, including immunotherapy, has improved survival but also made radiation treatment decisions more complex. Many of these trials did not allow prophylactic cranial irradiation
(PCI) or consolidative thoracic radiation. In patients deciding against PCI due to the known neurocognitive effects, potential and subsequent brain metastasis from SCLC were thought to require whole brain radiation therapy (WBRT). Conventional wisdom was if focal MEDICAL FORUM | CANCER CARE
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Key messages ALND is associated with significant morbidity which greatly influences patients' quality of life SLNB offers accurate staging with fewer complications in the clinically node negative breast cancer patient Neo-adjuvant chemotherapy is converting a greater number of node positive patients to node negative, unlikely to benefit from full ALND. disease ALND or nodal radiation may not be warranted. The results of trials assessing subsequent management, (e.g. positive sentinel node adjuvant therapy (POSNOC) which included Australian patients), are eagerly awaited. Neo-adjuvant chemotherapy (NAC) use is increasing especially in biological subtypes where response can further tailor management. For tumours which are either triple negative or overamplify HER2, a complete pathological response can be seen up to 70% of the time. This gives prognostic information and allows for additional therapy in those without a complete response, leading to improvement in overall survival. In patients with clinical node negative disease, the timing of SLNB in relation to NAC was initially controversial. It has now been shown to be reliable and safe to be performed following completion of NAC. For those with node-positive disease in the outset, we can see a complete pathological response in the lymph nodes up to 40% of the time, meaning the traditional treatment of ALND may not be required. Nodal response is not
techniques were used, patients would inevitably progress in other areas due to the high incidence of brain metastasis associated with this disease. The FIRE-RT study assessed radiosurgery (SRS) as a treatment option instead of WBRT. It found no survival difference between SRS or WBRT. However, in patients treated with SRS, the median time to MEDICAL FORUM | CANCER CARE
always predicted by response in the breast. Accurately identifying this subgroup of initially node-positive patients who may then avoid ALND is clinically challenging, with 5060% of patients who have a node that appears to have regressed on imaging will have residual disease in the axilla. Restaging of the axilla postNAC may be a useful adjunct. However, several studies have shown the limitations of SLNB in node-positive patients after NAC with unacceptably high false negative rates. Using a dual tracer, (both patent V blue dye and a radioisotope) increased the SLN identification rate and contributed to the lower false negative rate when at least two LN are removed, but still gave a false negative rate above the accepted threshold of 10%. Targeted axillary dissection (TAD) is a surgical technique that has been developed to further lower the false negative rate and accurately restage the axilla. It is useful in the cohort who were clinically node positive on presentation but have a good clinical response following NAC. Prior to any treatment beginning, the abnormal nodes are identified on ultrasound imaging. A marker clip is placed in the largest, most abnormal node proven to be FNA positive, under imaging guidance. This can subsequently be used to localise the lymph node for excision under hookwire, radioactive or magnetic seed guidance. At the time of surgery, the targeted node is excised along with a SNB using dual tracers. The recommendation is to remove at least three nodes. This technique has lowered the
progression in the brain was 8.1 months, which is considerable in this setting. Despite these advances, there is an urgent need for improved access to cancer treatments for Indigenous Australians. Cancer is now the leading cause of death in this population, and lung cancer is the leading type of cancer-causing death. Unfortunately the gap is worsening.
false negative rate to 2%, likely aided by the finding that the clipped node is not the sentinel node in about 20% of cases. Many centres in WA are now adopting this approach in patients with a low nodal burden prior to NAC and a good clinical and radiological response. This is done in a multi-disciplinary setting within department guidelines and protocols. A TAD is considered positive when any amount of residual disease is found in the axilla, and currently standard of care is to perform a completion ALND. Long-term follow-up is awaited for this group, as well as information on the role of nodal radiation in this setting. Balancing the importance of prognostic information in axillary staging with the significant morbidity associated with axillary treatment means the management of the axilla in breast cancer will remain dynamic. Trials are ongoing and results will influence future care. Hopefully we can provide accurate staging, low regional recurrence rates and improved overall survival while safely avoiding the lifechanging, long term morbidity associated with axillary surgery. – References available on request Author competing interests – nil
Read this story on mforum.com.au
From 2010 to 2019, the death rate from cancer increased by 12% for Indigenous Australians but deceased by 10% for nonIndigenous Australians. Author competing interests – Dr Bucknell receives research funding from RANZCR and the Peter MacCallum Cancer Centre Foundation. He has received honorarium from Astra Zeneca.
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Clinical research – key to improving outcomes in childhood cancer By Dr Santosh Valvi, Paediatric Oncologist, PCH Survival rates for children with cancer have improved significantly since the 1980s with estimated fiveyear survival rate rising from 28% to more than 80%. While newer modalities of treatment and better supportive care have contributed to this dramatic survival improvement, the important role played by clinical trials over the years cannot be underestimated.
not otherwise available. We also collaborate closely with the Telethon Kids Institute Cancer Centre and have translated home-grown research into an international clinical trial called SJ-ELIOT, in partnership with the world-renowned St Jude Children’s Research Hospital in Memphis, USA, for patients with relapsed medulloblastoma.
Although about 400,000 children and adolescents are diagnosed with cancer globally each year, childhood cancers only account for 1% of all newly diagnosed cancers and are relatively uncommon. With limited patient numbers, collaboration among multinational consortia and cooperative groups to share research ideas and run clinical trials is essential.
In 2017, we expanded clinical trial capabilities following establishment of our specialist Early Phase Clinical Trials Unit. This ensures that all WA children with cancer have the opportunity to access the latest therapies (e.g. molecularly targeted therapy, immunotherapy, and precision medicine approaches).
As an oncologist, delivering difficult news to families regarding the clinical outcome for their child is never easy, but discussion of potential enrolment onto a clinical trial, changes that conversation by offering hope. We have a range of clinical trials open for our patients at Perth Children’s Hospital (PCH). Phase I clinical trials investigate a new drug, schedule, or combination of agents to determine safety and toxicity. Phase II trials investigate tumour-specific efficacy of an agent, in a dose and schedule determined from a phase I trial. Phase III trials compare a new drug or drug combination with the current standard treatment, usually in a randomised fashion. Early phase (phase I and II) clinical trials are not generally expected to result in a cure, though these provide children with incurable cancers and their families an opportunity of doing something rather than nothing. The PCH Oncology Unit has participated in clinical trials conducted by the Children’s Oncology Group (COG) and its predecessors since the early 1990s. For newly diagnosed children with cancer, enrolment into phase III and some phase II clinical trials MEDICAL FORUM | CANCER CARE
Key messages Child cancer survival is improving Clinical trials can offer hope as well as knowledge This area is ever evolving.
represents a standard approach to paediatric cancer therapy. All patients and their families are offered participation in clinical trials if available. They are enrolled after an informed consent process. We have established a strong record of success in recruiting patients in clinical trials with nearly all of our patients enrolled where an appropriate trial is available. In cases where a frontline phase III trial is temporarily closed or unavailable, patients are treated as per the standard arm of the latest clinical trial, which in many cases is the standard therapy available for that particular cancer. In addition to COG, we have established successful partnerships with local, national, and international groups. The PCH Oncology Unit has recently joined several other international clinical trials consortia, which will deliver a broad suite of new clinical trials.
Precision medicine is an emerging paradigm in paediatric oncology using advanced molecular techniques to understand the genetic and biochemical profiles of cancers and guide the use of targeted therapies. It has predominantly been used when a patient relapses, however, we have also had the opportunity to use targeted agents in some newly diagnosed patients where standard therapy was considered to be less effective. This is a field with continual advances being made. Before opening this unit, travelling interstate was the only option for our patients wanting to participate in early phase trials. Since inception, a total of 33 new early phase clinical trials have been opened, with 67 patients enrolled, including recruitment of the first patients globally onto some of these trials. Achieving milestones such as this is not only the result of enormous work by our team but also reflective of the strong international reputation we have achieved and enables provision of world-class care for Western Australian children with cancer. Author competing interests – nil
We have built strong collaborations with industry, allowing us to offer families access to novel treatments AUGUST 2022 | 51
Mental disturbance in the perinatal period By Dr Caroline Crabb, Perinatal Psychiatrist, Subiaco There is growing awareness of perinatal depression, but anxiety disorders are more common and often overlooked, affecting up to 30% of pregnant women. There is less awareness still of perinatal obsessive compulsive disorder (OCD), yet up to 40 out of 100 anxious and/or depressed women also report obsessional, intrusive thoughts of harming the baby.
while kept waiting for the mother, who may become avoidant of holding them, or keep the baby waiting for the next feed as feeding bottles and equipment are laboriously sterilised. The tormented parent may become hypervigilant, constantly checking their baby is safe or breathing when asleep. Compulsive rituals such as these may temporarily calm the mind, but often feel shameful and stressful.
A 2012 meta-analysis reported a significantly higher risk of OCD in pregnant and post-partum women than in non-pregnant women. Important risk factors include genetic, hormonal, neuroendocrine and immunological. Those prone to anxiety by temperament or pre-existing anxiety or impulse control disorders are more vulnerable to developing OCD. Trichotillomania, body dysmorphic disorder, skin picking disorder and hoarding disorder are often co-morbid with OCD. Working women, particularly those with perfectionistic tendencies, are often susceptible. They often strive to excel, upholding themselves to relentlessly high (and unrealistic) self-standards; the unpredictability and early chaos of motherhood can rattle their sense of competence and make them question their selfworth. An exaggerated sense of accountability increases shame and guilt over perceived minor failures. Although they know that many anxieties are irrational, they are compelled to go to extreme lengths to prevent the perceived threat of harm. This then creates a cycle of anxiety and, sometimes, counterbalancing compulsions. These mothers tend to suffer in silence, unable to share their sense of failure in carrying such a responsibility to keep the dependent baby alive. They are driven to conceal their problems, worrying if they disclose obsessional thoughts their babies will be placed in care. Obsessional thoughts postpartum can include ruminations of harm to the infant, but these are 52 | AUGUST 2022
Prevention and treatment
not associated with actual harm (unlike the delusions in a psychotic disorder). Therefore, it is important to distinguish obsessive ruminations from delusions and provide reassurance to suffering mothers, who are usually less likely to intentionally harm their babies due to associated avoidant behaviours. Obsessional thoughts, impulses or images can feel very disturbing during an already vulnerable life transition, further heightening anxiety and fear, which may develop into avoiding the baby while questioning her fitness to parent. The anxious ruminations can overwhelm the mother’s coping defences, resulting in shame and torment and, if left untreated, lead to suicidal ideas. Many new mothers with OCD are understandably too ashamed or embarrassed to confide in others, or to seek help. Often, they will not share their fears even with their partner or health professionals. Importantly, the ruminations and compulsions often divert the mother from interacting with her baby, potentially resulting in attachment disruption and behavioural disturbance in the infant. Anguish increases with the hungry, screaming baby’s escalating rage
Generally, pregnant women welcome inquiry about their emotional wellbeing. This can bring relief and reduce feelings of stress and isolation, mitigating societal pressure to be happy and excited at this time. Introducing discussion early as part of routine antenatal care reduces stigma and increases the chance that problems will be identified early enabling helpful psychoeducation. Organic screening is important for identifying any underlying biological determinants that may be contributing, (e.g. thyroid dysfunction, iron deficiency anaemia, vitamin D, B12 and folate deficiencies), especially in new onset depression or anxiety postnatally. Providing a ‘safe non-judgmental space’ is paramount to engendering a trusting therapeutic relationship. Clinicians are often unaware of their own powerful capacity to represent or trigger positive or negative images of the internalised ‘maternal imago’ (e.g., arouse fear, self-criticism or create a comforting experience). Reassurance that intrusive thoughts of accidental or deliberate harm to the baby, accompanied by guilt or shame in harbouring such thoughts, is common, and will be valued. This can be normalised as a symptom of perinatal anxiety or depression. Sensitive assessment of suicidal and infanticidal ideation dictates the appropriate level of supervision, whether at home with family support, in secondary continued on Page 53
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The overactive bladder By Dr Elayne Ooi, Urologist, Mount Hawthorn & Albany Overactive bladder (OAB) is defined as “urinary urgency, usually with urinary frequency and nocturia, with or without urgency urinary incontinence (UUI), in the absence of UTI or other obvious pathology”. The prevalence in adults aged over 18 is 10.8% in men and 12.8% in women. UUI is the most bothersome symptom. History should include sexual, gastrointestinal and neurological symptoms. Perform an abdominal and pelvic examination checking for: vaginal atrophy, pelvic floor muscle weakness, prolapse and leakage with cough in females; phimosis, meatal stenosis, and prostate enlargement in males. Spine tenderness or deformity, decreased perianal sensation, lax or tight anal sphincter tone and lower limb weakness or paraesthesia suggest underlying neurological disease. Use bladder diaries and pad weights to evaluate the types and volumes of fluids consumed, number of voids, volumes voided and the degree of leakage. Useful investigations are UEC, HbA1c, urine MCS and urinary tract ultrasound. Comorbidities that can aggravate the condition include cardiac failure, diabetes mellitus, sleep disturbances (e.g. OSA, restless legs) and neurological conditions (e.g. MS,
Parkinson’s, stroke). Medications such as diuretics and beta blockers may also exacerbate symptoms. Behavioural and lifestyle changes are first-line management and can be initiated by general practitioners. Restrict evening fluids and consumption of bladder irritants or diuretics (caffeine, alcohol, acidic and spicy food). Increase fibre intake to prevent constipation. A 5-10% weight loss substantially improves continence, though evidence base relates to stress rather than urge leakage. Pelvic floor muscle exercises and bladder retraining help to stabilise the proximal urethra, improve urethral function and increase the inhibition of urgency, detrusor contractions and incontinence. Anticholinergics reduce detrusor smooth muscle contractility and involuntary spasms, resulting in one less micturition per 48 hours, one less leakage episode per 48 hours and average 54ml increase in maximum bladder volume in medication vs placebo group. Interestingly, there is a striking placebo effect, with cure or improvement reported in 60% medication vs 45% placebo groups. Dry mouth is the most common and bothersome adverse effect,
with high discontinuation rates. Current evidence suggests that no anticholinergic drug is clearly superior to another. Transdermal oxybutynin has lower rates of adverse effects and can be prescribed as a PBS Restricted item if the patient cannot tolerate oral oxybutynin. Solifenacin and darifenacin did not appear to worsen cognitive impairment short term. It is best to avoid using anticholinergics in the elderly patient due to association with increased dementia incidence and cognitive decline. When other alternatives are inappropriate or ineffective, the risks and benefits should be clearly discussed, lowest effective dosage used, and clear time frames set for proposed duration of treatment with regular cognitive assessment. Mirabegron relaxes detrusor muscle and increases bladder capacity. It is a useful first-line drug in elderly patients as it does not impair cognition, and males who often have bladder emptying problems due to prostate enlargement. Efficacy is modest, with reduction of incontinence episodes of 1.5 a day vs placebo 1.1. Blood pressure monitoring is recommended due continued on Page 55
Perinatal mental health continued from Page 52 health services, or in an inpatient psychiatric mother and baby unit. Helping a mother understand the underlying causes of her suffering improves self-esteem and promotes confidence during a potentially frightening time, when she is in a state of transformation. Each woman’s representations of her mental image of an archetypal or idealised mother in pregnancy MEDICAL FORUM | CANCER CARE
are unique – a composite of derivations of her emotional autobiography, psychosocial situation and unconscious make-up. Irrational concerns can be overcome by safely exploring the parent’s fears in psychotherapy. Cognitive behavioural therapy (CBT) is particularly effective in helping people with OCD by gradual exposure and managing anxieties without resorting to compulsive rituals.
Short-term anxiolytics such as Lorazepam, with or without SSRI agents, may be useful. Individualised risk benefit analyses are needed when weighing indication for psychotropic drugs in the perinatal period, accounting for the risk of untreated illness on the mother and foetus or infant. Author competing interests- nil
AUGUST 2022 | 53
Resistance exercise: frontline defence against sarcopenia By Dr Cassandra Smith, Exercise Physiologist, & Dr Marc Sim, Nutritionist, ECU Sarcopenia is the loss of muscle mass in conjunction with reduced strength and/or physical performance. In July 2019, sarcopenia was recognised as a disease with its own International Classification of Disease, ICD-10 code (M62.84). It can also occur secondarily to chronic disease (e.g. cardiovascular disease and diabetes). At least five definitions for its clinical identification exist, most include three themes – low muscle mass, strength and physical performance. Currently, no pharmacological treatment exists for sarcopenia. The most effective intervention to improve muscle mass, strength and performance is lifestyle strategies such as progressive resistance training combined with a healthy diet that includes adequate dietary protein and energy intake. The resistance exercise prescription can probably be summarised as completing at least 2-3 days a week of weight training that includes whole body movements (upper and lower body exercises), performed over 2-4 sets and using a repetition range that can be completed using a moderate to heavy intensity load until fatigue. For adults over 65, the general recommendation for daily protein intake is 1.1 to 1.2g/kg/day, even for those undertaking resistance exercise, and for those with sarcopenia the requirement may increase to 1.5 g/kg/day. Diets rich in vegetables providing a plethora of nutrients including vitamin K, nitrate and organosulphur compounds are also likely to support musculoskeletal health. A daily 75g serve of green leafy and/or cruciferous vegetables (e.g. broccoli, cauliflower, cabbage) would represent rich sources for these nutrients. Most importantly, including clinical nutrition expertise in the management of chronic disease including sarcopenia should be 54 | AUGUST 2022
Key messages Sarcopenia is common in older adults and associated with falls, fractures and cardiovascular disease 75% of older adults are not meeting recommended physical activity guidelines The only intervention consistently shown to improve muscle mass, strength, and physical function in older adults is resistance exercise, combined with a balanced diet. actively promoted to patients as part of their treatment plan. A surprisingly low number of older adults currently meet exercise guidelines, with only one in four over 65 considered sufficiently active. Low physical activity and sedentarism are significant risk factors for sarcopenia and other chronic diseases. Based on official guidelines, adults aged over 65 years should be completing at least 30 minutes a day of physical activity on most days of the week, incorporating activities such as fitness, strength, and balance exercise. This includes any physical activity that increases heart rate and ideally these activities include weight bearing. The biggest barrier to exercise participation in older adults has been shown to be related to poor health or injury, yet inadequate lifestyle choices (i.e. inactivity, insufficient diet) contribute greatly to compromised health. Overcoming this barrier to physical inactivity begins with good education, setting achievable and realistic goals and working with an individual to find easy-toimplement strategies to improve their physical activity levels. In our clinical experience many older adults, including those with or without chronic disease, are under prescribed exercise by their doctors or have been advised that exercise participation may be unsafe due to
age or chronic conditions. It is important to differentiate between physical activity and exercise. Physical activity refers to activities that are a part of one’s usual daily activity (e.g. household chores or walking to the letterbox). There are many opportunities to be physically active every day, and this should be encouraged for all older adults. Some easy to implement examples: • Walk or ride to work • Parking the car at the back of the carpark when you go to do your grocery shop • Walking every aisle at the supermarket • Choosing the stairs instead of the lift If completing 30 minutes of physical activity in one session is not achievable, benefits can still be achieved in smaller increments (e.g. three sessions of 10 mins). Exercise is a more structured and focused approach usually performed for a particular duration or intensity. Exercise is safe if individualised and prescribed within the recommended guidelines. For patients who have complex medical histories, when assessed and prescribed by an accredited exercise physiologist, appropriate modifications and individualisation can still occur enabling safe exercise participation. For those with sarcopenia traits, it is always recommended that before beginning a new exercise routine a GP is consulted for a general health screen and they should be able to refer to an accredited exercise physiologist who can prescribe an individualised plan taking into consideration the patients’ medical history, medications, risk factors and goals. ED: Dr Smith is a postdoctoral research fellow and accredited exercise physiologist, and Dr Marc Sim is a Senior Research Fellow (Nutrition) both at ECU. Author competing interests – nil
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The overactive bladder continued from Page 53 to risk of hypertension (7.3%). Caution is advised in patients with prolonged QT interval or taking drugs metabolised by CYP2D6 (e.g., flecainide imipramine).
Urological referral This should be considered in these situations (1) Persistent microhaematuria or painless macrohaematuria (2) Recurrent UTIs, renal decline or obstructive uropathy (3) Risk factors for urological malignancy (4) New persistent symptoms without explanation or obvious cause (5) Severe symptoms refractory to first-line treatment Flexible cystoscopy with or without urodynamic studies are usually performed to exclude bladder pathology and assess the type and severity of voiding dysfunction prior to intervention. Posterior tibial nerve stimulation
(PTNS) delivers electrical impulses to the sacral plexus through an acupuncture needle inserted in the ankle near the posterior tibial nerve. Studies show significant improvement in frequency, urgency, nocturia, incontinence, maximum cystometric capacity and compliance. Induction phase includes 12 weekly sessions in the first three months. Tapering phase is five sessions over the next three months. Maintenance phase is one session monthly ongoing. Adverse effects are rare, apart from minor discomfort at needle site. PTNS offers a low-risk option but is laborious with poor compliance rates. Intravesical botulinum toxin injections are administered cystoscopically under local or general anaesthetia every 3-15 months (median 7.5). Efficacy is superior to pharmacotherapy, with urge incontinence episodes per day reduced by half, frequency decreased by >2 times and 23% of patients fully dry. Patients have consistent or increasing duration of
effect with subsequent treatments. Increased post-void residuals in the first few weeks is common. Sacral Neuromodulation (SNM) delivers low-amplitude electrical impulses to the sacral nerve roots from an MRI-compatible pulse generator implanted in the gluteal region. Half of patients with UUI demonstrated >90% reduction in leakage episodes, with continued success at four years and cure rates of 15%. When compared over two years, SNM and botulinum toxin injections are equally effective. Experimental laser treatment and acupuncture are two other modalities advertised and used in OAB management. However, the quality of evidence remains low and are not generally recommended. – References available on request Author competing interests – nil
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BOOKS
Take a guided tour of autopsies Albany GP Dr Meryl Broughton spent 10 years doing autopsies as an after-hours job. In her first book, she’s sharing the cases which lift the sheet on real autopsies – and her passion for solving a mystery.
By Ara Jansen
In her wonderfully titled book Autopsies for the Armchair Enthusiast, Dr Meryl Broughton exudes an obvious passion for solving the mysteries of the sudden and unexpected deaths of those who ended up on her autopsy table. Laced with a good dose of respectful humour, the former forensic pathologist delves into the varied cases she worked on and shares the stories behind them. As a reader you’re able to get up close and stand next to her as she weighs, measures, digs around and investigates. “I loved the process of doing an autopsy,” explains the Albany-based GP with a cast-iron stomach. “I like the physicality of performing an autopsy – looking at the tissues, touching, feeling and smelling, it’s a sensory experience. “The other thing I liked about it was there was plenty of time. You weren’t under pressure like a surgeon. I also liked the idea of thoroughness, not missing anything and looking for an answer to a problem that’s meant to be solved. There was often a mystery. “As a GP you see a disease at the start and then you follow it through and get a better idea of what’s going on as you go along. It’s hard going and there’s a lot of uncertainty, so it was good to have a medical side interest that was completely different but still had relevance.”
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BOOKS
Autopsies for the Armchair Enthusiast shares stories about the cases Meryl worked on. Names and some details have been changed to make for a better read, but these are the cases which came across her table. Collectively they were sudden and unexpected deaths by ultimately natural causes, but Meryl’s job was to figure out how, even if the circumstances were sometimes less than obvious or straightforward. She did about 110 autopsies over a decade as a forensic pathologist and used her personal files and notes to jog her memory or fill in the blanks about each case. “What you see on TV is not quite what you get in reality,” explains Meryl. “I wanted to use the coronial autopsies to go through the human body’s systems sequentially showing what can happen. “I also looked for statistics on things like how many people actually die on the toilet or in the laundry. That’s part of the reason I ended up writing a book for general readers rather than a medical book. You don’t have MEDICAL FORUM | CANCER CARE
“What you see on TV is not quite what you get in reality, I wanted to use the coronial autopsies to go through the human body’s systems sequentially showing what can happen.”
shows like CSI or Silent Witness and true crime being so successful without people being interested in it. I also wanted to tell a good yarn.” Privacy was of course a consideration in how Meryl told her stories and has honoured the dead through the “sanctity of the consulting room”. She couldn’t exactly approach the patients and get their permission so she had to be careful how she laid out the cases in her book. While these days people seem happy enough to post on social media all about their gall
bladder operation, Meryl wanted to be respectful towards her late patients. “Giving the people in the book fake names suddenly helped them take on a fictional life of their own. There are some fictional elements because I didn’t always have all the information I needed, but the medical information is accurate and real.”
continued on Page 58
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BOOKS
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Take a guided tour of autopsies continued from Page 57 Originally from Perth, Meryl did three years of medicine at UWA, but after marrying, moved to Victoria and completed her degree at Monash University in 1980. She did anatomical pathology for several years before going into rural general practice and then became vocationally registered in 1992. On returning to WA and settling in Albany in 2003, it was a case of perfect timing. The GP who had been doing local autopsies for the coroner was due to retire and because Meryl had that unusual skill set, she ended up being the natural choice. She was also in the unique position of being the only person doing autopsies outside Perth. Eventually she was also the last GP in the state and maybe even the country, to conduct regional autopsies. Separate from the stories, Meryl’s book also charts the end of an era for regional medicine. When a new regional hospital was planned for Albany, no post-mortem room was included in the morgue, putting the nail firmly in the coffin. These days autopsies are performed in Perth and there’s no call – or local facilities – for Meryl to conduct examinations. She was eventually inspired to write Autopsies for Armchair Enthusiasts. The first draft was completed in 2014 and after finding a kindred publisher, it was released late last year. Meryl doesn’t aim to only entertain with the interesting situations and mysteries she was called on to investigate, but also to educate readers on how their bodies’ systems work and encourage them to improve their own health. With a view to helping make positive small and large steps, she hopes they will stave off prematurely ending up on an autopsy table. Encouraged by the success of this book, Meryl’s next writing project is likely to be a medical memoir on the weird, wonderful and interesting world of being a country GP. ED: Autopsies for Armchair Enthusiasts is published by Bad Apple Press, $27.99
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The Audi EOFY sale has been extended 5 years / 75,000km scheduled servicing* 5 years roadside assistance+ 5 year manufacturer’s warranty# $500 to use on any Audi Aftercare Protection Package~
A wide range of Audi models in stock now. Offer ends soon, only at Audi Centre Perth.
Audi Centre Perth Overseas model with optional equipment shown. *Scheduled servicing for 5 years from the date of first registration or 75,000kms (whichever occurs first) as per the manufacturer’s recommended scheduled servicing specifications. Excludes wear and tear items and any additional work or components required. +Roadside assistance terms and conditions apply. #5 year manufacturer’s warranty commences on the date of first registration. Terms, conditions and exclusions apply. ~$500 Aftercare credit is valid on the purchase of any in-stock new Audi vehicle from Audi Centre Perth, for use on any Audi Aftercare Protection Package, ordered at the time of purchase. Not valid for vehicle servicing and parts. Offer valid until 31/12/2022. *#^~ Available on Audi new stock vehicles only (excluding all demonstrator models and S and RS models) purchased and delivered between 1/6/2022 and 14/8/2022. While stock lasts. Not available to fleet, government or rental buyers, or with other offers. Exclusive to Audi Centre Perth. Audi Australia may withdraw, change or extend all offers. MD27161. MRB7834.
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WINE REVIEW
Fine flavours from old vines The Yukich family are Swan Valley pioneers and their purchase of Houghton Estate has returned the vineyard to Western Australian hands. Now Nikola Estate is transforming those historic vines by the hard work of innovative winemaker Damien Hutton, who is producing some great new wine styles that show terrific freshness and flavour. The 2022 vintage white wines are real gems and recommended.
Nikola Estate 2022 Chenin Blanc Chenin Blanc is one of the classic Swan Valley varieties and the Nikola Estate 2022 iteration is setting the standard. Light straw in colour with some lifted aromas of lemon and melon. A soft, delicate, fruit-driven palate and clean natural acidity. I enjoyed the approachable style of this wine, which would be great for any seafood dish.
Nikola Estate 2021 Verdelho The Swan Valley produces the best Verdelho in Australia and this wine is from plantings established in 1958. The winemaker has selected just the free-run juice to enhance the flavour profile. A fabulous nose of honeysuckle with a light fruit palate of melon and tropical fruits. This wine has collected an array of medals with good reason and the fresh style would be perfect for spicy Asian foods.
Nikola Estate 2022 Regional Rose For me, Grenache rose is the gold standard rose variety and this rose is all Swan Valley fruit with a real Provence feel. Light salmon in colour with aromas of confectionary bursting from the glass. Clever winemaking has captured freshness and flavour. A soft, lengthy palate with cherry and floral flavours make this a truly enjoyable rose. Only just bottled and I recommend this in your cellar ready for spring.
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Review by Dr Martin Buck
Nikola Estate 2021 Grenache Shiraz Mourvedre The GSM blends are popular because they bring together the best of the varieties in one package. This GSM is from Geographe fruit and highlights the flexibility of Grenache. Plenty of berries and pepper on the nose and a medium-bodied palate makes this a very drinkable wine. The brief ageing in seasoned French oak results in soft tannins letting the berry fruit shine through. Perfect for your favourite Italian dish.
Nikola Estate 2020 Shiraz Shiraz from the Swan Valley is underrated and Nikola Estate’s shiraz highlights the old vine fruit from the original Houghton’s vineyard that produces great complexity. A vibrant deep crimson in the glass and inviting complex fruit and berry aromas. On the palate there are silky tannins to balance the big, juicy fruit flavours. This is a great value, Hermitage-style wine perfectly matched for a beef bourguignon.
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THE VEIN CLINIC CELEBRATES 8 YEARS
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Key milestones to date
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Looking to sell your practice? )RU D FRQǓGHQWLDO GLVFXVVLRQ FRQWDFW XV WRGD\ Dr BrHQGD 0XUUison 0 0418 921 073 ( Brenda.Murrison@breckenhealth.com.au Damian Green 0 0423 844 268 ( Damian.Green@breckenhealth.com.au