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Preference: Statistics, epidemiology and research design

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Research suggests Australians confused about sun protection

Fewer than one in 10 Australians understand that sun protection is required when UV levels are three or above, according to research by the Cancer Council and QIMR Berghofer Medical Research Institute.

Melanoma is the third most common cancer in Australian men and women. Australia and New Zealand have the highest melanoma rates in the world with Queensland incidence rate of 71 cases per 100,000 people (for the years 2009-2013), vastly exceeding rates in all other jurisdictions nationally and internationally.

Melanoma is the most common cancer in young Australians (15–39 year olds) making up 20 per cent of all their cancer cases.

Heather Walker, Chair of Cancer Council Australia’s National Skin Cancer Committee, said the latest National Sun Protection Survey results showed a clear gap in Australians’ knowledge. Forty per cent of Australians are still confused about which weather factors cause sunburn.

“This new research shows that Australians are still very confused about what causes sunburn, which means people aren’t protected when they need to be,” she said.

“In summer 2016-17, 24 per cent of Australian adults surveyed incorrectly believed that sunburn risk was related to temperature, while 23 percent incorrectly cited conditions such as cloud cover, wind or humidity.

“It’s important for us to reinforce the message that it’s ultraviolet radiation that is the major cause of skin cancer – and that UV can’t be seen or felt. It’s a particularly important message this time of year. In autumn, temperatures in some parts of the country are cooling, but UV levels right across Australia are still high enough to cause serious sunburn and the skin damage that leads to cancer.”

Professor David Whiteman, Head of the Cancer Control group at QIMR Berghofer Medical Research Institute, said despite years of public education, encouraging Australians to protect their skin was an ongoing challenge.

“These findings show that very few Australians know when to protect their skin from the sun’s harmful rays,” he said.

“This is clearly a concern as it’s likely that Australians are relying on other factors, like the temperature or clouds, to determine when they need to slip, slop, slap, seek shade and slide on sunglasses.

“There is overwhelming evidence that, if used correctly, sunscreen prevents skin cancer – yet at the moment many Australians don’t even really understand when it’s required, and many are neglecting to use it altogether. We also know from previous research that 85 per cent of Australians don’t apply it correctly.”

Late last year, the Cancer Council National Sun Protection Survey showed that overall the proportion of adults slipping on clothing to protect themselves from the sun has decreased from 19 per cent to 17 per cent in the last three years.  

The Cancer Council believes there is a need for Government to continue to invest in skin cancer campaigns to ensure adults remain vigilant about reducing their UV exposure.

“Australia hasn’t had Federal funding for a skin cancer prevention campaign since 2007 – this latest data suggests adults are becoming complacent about UV and demonstrates the urgent need for a refreshed national campaign,” Professor Sanchia Aranda, Cancer Council Australia Chief Executive Officer said.

Cancer Council’s SunSmart app provides local UV alerts and sun protection times and can be downloaded free on the App Store or Google Play.

MEREDITH HORNE

British study finds more than one third of cancers could be avoided with lifestyle changes

A landmark study by Cancer Research UK found that being overweight is a contributing factor to cancer – and it’s growing.

Excess weight now caused 6.3 per cent of all cancer cases, rising from 5.5 per cent in 2011.

The latest figures, calculated from 2015 cancer data, were analysised in the study to examine preventable cancers and to find ways individuals can help to minimise their risks to develop cancer.

Sir Harpal Kumar, Cancer Research UK’s chief executive said: “This research clearly demonstrates the impact of smoking and obesity on cancer risk. Prevention is the most cost-effective way of beating cancer and the UK Government could do much more to help people by making a healthy choice the easy choice.”   

Cancer Research UK’s research found more than a third of all cases of cancer were avoidable – some 135,000.

Smoking in the United Kingdom still remains the biggest preventable cause of cancer despite the continued decline in smoking rates.

Tobacco smoke caused around 32,200 cases of cancer in men (17.7 per cent of all male cancer cases) and around 22,000 (12.4 per cent) in women in 2015, according to the research published in the British Journal of Cancer.

Cancer UK Research one of the biggest messages that they thought should be taken from the research was more action was needed to tackle the “health threat” of obesity.

Professor Linda Bauld, Cancer Research UK’s prevention expert, said: “Obesity is a huge health threat right now, and it will only get worse if nothing is done.

“The UK Government must build on the successes of smoking prevention to reduce the number of weight-related cancers. Banning junk food TV adverts before the 9pm watershed is an important part of the comprehensive approach needed.”

The research found that the third most preventable cancer in the UK was overexposure to UV radiation from sun or sunbeds. This directly caused about 13,600 cases of melanoma skin cancer a year, 3.8 per cent of all cancer cases.

Other preventable causes of cancer included drinking alcohol and eating too little fibre.

Cancer Research UK was keen to point out however, that is not a simple exercise to point to one thing alone to stop cancer. It was more an endorsement of the idea that many cancers were potentially preventable.

Professor Mel Greaves, from the Institute of Cancer Research, in London, said there was still many areas to be explored further in how to reduce cancers.

“If obesity could be avoided, the impact on cancer rates is uncertain – but they would almost certainly decline significantly,” Professor Greaves said.

“Given the currently high rates of obesity in young people, this represents (like cigarette smoking) a major societal challenge beyond the bounds of the medical arena.”

A copy of the study can be found at: https://www.nature.com/articles/s41416-018-0029-6 .

MEREDITH HORNE

Funding of the public sector is vital albeit intangible

I have read the recent superb article on public hospital funding by Chris Johnson with great interest (Australian Medicine March 19, 2018 Business as usual not good enough for public hospital funding).

As a Consultant Radiologist, I work full-time in a public tertiary centre after having worked for 20 years in another system entirely public funded. I was a Consultant in the UK before working in Australia. I love my career in medicine.

Your sentiment (that of AMA President Dr Michael Gannon, who is quoted in the article) is strongly felt. The UK will suffer for outcomes and investments but couldn’t stretch the public dollar any further. There has been much brow-beating. We have produced quality research and are ever resourceful around cost savings.

The continued funding of the public sector is vital but intangible. It is grossly under-valued. The smaller units operate in isolation and ‘re-invent the wheel’ without much sharing of good practice. Tertiary centres rarely instruct.

In my personal experience, the public sector does most of the time-consumptive training of medical students and registrars – tomorrow’s doctors. The public sector deals with the most difficult and severe cases that the private sector has no interest in and positively ignores. The most needy don’t seem to have private health cover.

Friday afternoon – bank holidays. The public system is ‘open all hours’ at whatever cost. The private sector will judge profitability around out-of-hours work. The private sector doesn’t appear keen on running Consultant-heavy multi-disciplinary meetings that are unfunded for those involved but in reality save thousands of dollars around unnecessary patient care, unnecessary operations, needless investigations and potential complications. The medical literature and evidence base is deficient here for sensible guidance. There is no financial incentive. 

However, if as a patient, you attend a private provider as opposed to a public environment, you will be more likely to see a Consultant ‘at the front door’ who might avoid a hospital admission through clinical experience and expertise. 

Undoubtedly, some clinical scenarios –  myocardial infarction, trauma and stroke – will need urgent unpredictable input while the private sector books out-patient care and over-investigates the fringes of medical need. Some conditions can benefit from a period of observation before a myriad of expensive tests are booked in parallel. There is little priority of investigations. It’s everything now! Paradoxically, volumes of needless work will generate significant incomes in many environments.

Publicly, more junior individuals will assess the most needy, admit to beds and order downstream costly investigations while they await any senior input. With so many providers, joined-up patient care is a diminishing reality. Conflicting interests abound. Some services are duplicated locally in a costly fashion without any scrutiny or accountability. What is a tertiary centre but a ‘dumping ground’ for cases the private sector can’t deal with? 

To many, the current system could be perceived as doctor-centred service without a patient-facing, single funded stream-lined approach. If the efficiency of the NHS had decent financial investment it would be unbeatable. Obvious gains are evident without a quick fix. Juniors have known it no other way and more and more accept the inequalities.

Who can intervene with a feeling of disorientation in such a complex setting?

Name withheld by request

[Comment] Measuring Humanity: hip-hop as evidence for health inequalities

Dear Human (video), a hip-hop video was developed as part of the project Measuring Humanity.1 Working with marginalised groups, the participant-led research programme uses bottom-up creative community engagement to challenge policy makers and academics to reassess what counts as evidence when developing policies, practices, and recommendations. The video features rapping written using co-produced data from marginalised community members, health and voluntary sector practitioners, and researchers.

Bringing pharmacists into the fold

BY DR RICHARD KIDD, CHAIR, AMA COUNCIL OF GENERAL PRACTICE

It has been almost three years since the AMA put forward its proposal to make non-dispensing pharmacists a key part of the future general practice healthcare team. Our advocacy on this issue has not wavered and since we launched our policy more evidence has accumulated to support the valuable role pharmacists can play when they are integrated into the general practice team.

General practice pharmacists would enhance medication management and reduce hospitalisations from adverse drug events (ADEs).  An independent analysis from Deloitte Access Economics (DAE), which was released with the AMA’s proposal, showed that integrating pharmacists into general practice would deliver a benefit-cost ratio of 1.56. If general practices were supported to employ non-dispensing pharmacists as part of their healthcare team, they would be able deliver real cost savings to the health system, of $1.56 for every dollar invested.

An in-house pharmacist would be able to assist GPs address overprescribing and medication non-adherence by patients. We would see better coordination of patient care, improved prescribing, improved medication use, and fewer medication-related problems. Hospitalisation rates from ADEs would fall and our patients’ quality of life would be improved as would their health outcomes.

A recently released research article in the International Journal of Clinical Pharmacy, titled Pharmacists in general practice: a focus on drug-related problems, shows that where pharmacists are working within a general practice that their recommendations are more readily accepted by practice GPs.

This bears out research published in 2013 titled An evaluation of medication review reports across different settings, which had similar findings. Access to the patient’s medical file and the relevant clinical information within when conducting a medication review enabled recommendations that were more targeted and less conjectural. The recommendations from these better-informed reviews resulted in greater acceptance of the pharmacist’s recommendations by the GP.

With chronic disease on the rise, and an ageing population, it is estimated that there are more than 700,000 patients with co-morbidities who would benefit from a review of their medications. This figure represents just the top 10 per cent of patients who could benefit from having their medications reviewed. In-house pharmacists could be a valuable resource for patients in understanding their medications and how to use them.

With over 230,000 medication related admissions to hospitals every year at a cost of $1.2 billion per annum and patient medication non-compliances estimated at 33 per cent, the time has well and truly come for action on this front.

With another trial; utilising non-dispensing pharmacists in 14 medical centres across the greater Brisbane area; winding up, the AMA Council of General Practice is looking forward to hearing the interim results.

With increasing evidence that where pharmacists are integrated within general practice patient care is improved, the AMA continues to advocate for Government funding to make this an everyday reality for general practice and for patients.

[Department of Error] Department of Error

Park KB, Khan U, Seung K. Open letter to The Global Fund about its decision to end DPRK grants. Lancet 2018; 391: 1257—In this Correspondence (published online first on March 14, 2018), the following sentence should have read “UK is a Director of Interactive Research & Development.” This correction has been made to the online version as of March 15, 2018, and the printed Correspondence is correct.

[Department of Error] Department of Error

Iuliano AD, Roguski KM, Chang HH, et al. Estimates of global seasonal influenza-associated respiratory mortality: a modelling study. Lancet 2017; 391: 1285–300—In the Research in Context panel of this Article (published Online First on Dec 13, 2017), the first sentence of the Evidence before this study section should read “Previous estimates commonly attributed to WHO indicate that 250 000–500 000 deaths occur annually worldwide due to seasonal influenza viruses.” The last sentence of the second paragraph in the Methods section should read “Of the 15 remaining countries contacted, eight did not respond to collaboration requests, five were unable to share data by September, 2017, and two had insufficient quality vital records data.” These corrections have been made to the online version as of Jan 19, 2018, and the printed Article is correct.

[Correspondence] In support of UNRWA appeal for health and dignity of Palestinian refugees

Our research into the UN Relief and Works Agency (UNRWA)’s delivery of health services to Palestinian refugees during the Syria crisis1 puts us in a unique position to anticipate the challenges of the organisation’s current funding crisis.2 We have conducted over 90 interviews with health workers and managers, a series of systems modelling sessions, and rigorous analysis of UNRWA health data from 2007–16, and conclude the following.

[Correspondence] Type 2 diabetes

We read with great interest the Seminar (Feb 9, 2017, p 2239)1 on type 2 diabetes by Sudesna Chatterjee and colleagues. However, we were surprised by the articles selected and believe that detailed selection criteria with the level of evidence of reported studies would have been useful to the reader. According to the research method described, we would expect other papers to be cited, including meta-analyses of randomised controlled trials that could have balanced the authors’ outlook.2–6 For example, intensive glycaemic control probably has some beneficial effect on diabetic complications, such as non-fatal myocardial infarctions3–5 or retinopathy assessed with the Early Treatment Diabetic Retinopathy Study scale.