[Editorial] Promising the moon

In his last State of the Union speech on Jan 12, 2016, President Barack Obama endorsed what Vice President Joe Biden has called our generation’s “moonshot”—a renewed commitment to end cancer. Evoking the sentiment of the “spirit of discovery” and the imagery of American space exploration, Obama symbolically appointed Biden as the head of “ground control” in this mission for the remainder of the Administration’s term. Taking up this mantle, Biden, whose son died from brain cancer earlier in October, 2015, visited Penn Medicine’s Abramson Cancer Center in Philadelphia on Jan 14, and laid out an ambitious yet nebulous plan to accelerate research in the pursuit of curing cancer.

[Correspondence] Policy misperceptions and support for gun control legislation

Firearms kill more than 30 000 Americans annually.1 Although federal law requires licensed gun dealers to undertake background checks on people who purchase guns, private sales at gun shows and online are exempt from these checks. Universal background checks for gun purchases could substantially reduce the number of gun-related deaths in the USA.2,3 Despite strong public support for universal background checks (92% of 1446 people polled in one survey),4 Congress has failed to act. Some researchers have argued that this disconnect between public opinion and legislation is attributable to a gap in engagement between supporters and opponents of stronger gun control.

GP guide aims to end prostate confusion

The number of men undergoing unnecessary prostate cancer tests and procedures is expected to drop following the development of evidence-based clinical guidelines.

In a major step toward resolving decades of confusion and uncertainty regarding the detection and treatment of prostate cancer – the second most common cancer in men – the National Health and Medical Research Council has approved a set of clinical guidelines that can be used by GPs and patients to inform decisions about whether to test for the condition.

The detection and management of prostate cancer has been dogged by controversy amid concerns that shortcomings in the widely-used prostate specific antigen (PSA) blood test has led to over-diagnosis and treatment, leaving many men with serious side-effects including impotence and incontinence.

To cut through the uncertainty and provide clear evidence-based advice to practitioners and patients, Cancer Council Australia and the Prostate Cancer Foundation of Australia (PCFA) undertook a three-year process in which convened representatives from all the disciplines involved in testing, including urologists, pathologists, GPs, radiation and medical oncologists and epidemiologists, to develop consensus guidelines.

The result, PSA Testing and Early Management of Test-detected Prostate Cancer: Guidelines for health professionals, has been approved by the NHMRC as providing evidence-based recommendations for the use of PSA tests and managing patients following a positive reading.

The Cancer Council and PCFA said they hoped the guidelines would help doctors “navigate the daily professional dilemma of informing men about the risks and benefits of testing, and prevent scenarios where PSA tests are conducted without patient consent”.

The test for PSA in the blood is considered an unreliable market of prostate cancer and so it not considered appropriate for use in population screening.

But, in the absence of an effective alternative, many men choose to have it anyway.

The problem is that false-positives can lead to a patient having an invasive biopsy procedure, exposing them to the risk of serious side-effects.

The NHMRC estimates that for every 1000 men aged 60 (and who do not have an immediate relative with prostate cancer) who take the test annually for 10 years, two will avoid a prostate cancer death before 85 years.

But a further 87 will, as a result of a false-positive test, have an unnecessary biopsy. As a result of the biopsy, 28 will experience side-effects including impotence and incontinence, and one will be hospitalised.

The risk of a false-positive and the attendant unnecessary yet serious complications means that the decision to have a PSA test is not a straightforward one, and PCFA Chief Executive Officer Associate Professor Anthony Lowe said the new guidelines were intended to help doctors and patients navigate the decision to maximise the benefits of the test and minimise the harms.

“Contention about the PSA test has made it difficult for health professionals to take a consistent, evidence-based approach to the test,” A/Professor Lowe said. “While the debate has played out, thousands of men have continued to take the test, as it’s the only available biomarker to assist doctors in assessing a man’s prostate cancer risk.”

Cancer Council Chief Executive Officer Professor Sanchia Aranda said use of the guidelines should result in less over-treatment associated with PSA testing.

“The PSA test is an imprecise test, and has the potential harms as well as benefits,” Professor Aranda said. “Use of the guidelines will hopefully reduce the level of over-treatment and guide improved management of men with early stage prostate cancer until we have a better biomarker.”

Among other advice, the guidelines recommend:

an end to rectal examination of asymptomatic men by GPs;
no PSA test for men unlikely to live another seven years because of other health complaints;
harms of PSA tests may outweigh potential benefits for men older than 70 years; and
for men aged 50 to 69 years who decided to have PSA testing, tests should be conducted every two years, not annually.

The guidelines can be downloaded from: www.pcfa.org.au and wiki.cancer.org.au/PSAguidelines

Adrian Rollins

[Comment] The historian will see you now: introducing Case Histories

“I hope that Lord Grey and you are well”, wrote the Regency wit and clergyman Sydney Smith to his confidante Lady Mary Grey in February, 1836, “no easy thing, seeing that there are about fifteen hundred diseases to which man is subject”. Last year the editors of the Lancet journals announced the launch of The Lancet Clinic, a major online initiative which draws together an overview Seminar with the best current research from across the Lancet journals on 135 of the most globally important diseases.

[Comment] In appreciation of the peer-review heroes from 2015

The Lancet is responding to the increased volume of high quality research by not only expanding the number of specialty journals within our family, but also by publishing more research studies. In 2015, we published almost 20% more research papers than in the previous year. And we did this more quickly, by offering the possibility of 10 + 10 rapid publication for randomised controlled trials sent for peer review. We also launched The Lancet Clinic, published highly clinical and global health Commissions, and Series on topics as diverse as radiation and religion.

Wollongong academics disown anti-vax views

Health academics at the University of Wollongong have affirmed the lifesaving benefits of immunisation after their institution become embroiled in controversy over the decision to award a doctorate for a thesis questioning the safety and efficacy of mass vaccination programs.

Sixty-five senior medical and health researchers including Professor of Public Health Dr Heather Yeatman, Dean of Medicine Professor Ian Wilson, and Professor Alison Jones, Executive Dean of the Faculty of Science, Medicine and Health, have jointly signed a public statement backing the evidence supporting vaccination and its importance in preventing disease.

“The evidence is clear,” the statement said. “Immunisation protects children and saves lives.

“While individuals may express opinions, the international scientific evidence overwhelmingly supports immunisation to protect children from infectious diseases.”

A series of reports in The Australian newspaper revealed that Dr Judy Wilyman, described as an “anti-vaccination campaigner”, had been accepted for a PhD after submitting a thesis in which she criticised the National Immunisation Program (NIP).

In her thesis, Dr Wilyman argued that the implementation of mass vaccination programs like the NIP coincided with “the development of partnerships between academic institutions and industry” and notes the involvement of organisations including the World Bank, the International Monetary Fund, the Bill and Melinda Gates Foundation and UNICEF in urging population-wide immunisation.

“Whilst the Government claims serious adverse events to vaccines are rare this is not supported by adequate scientific evidence due to the shortcomings in clinical trials and long-term surveillance of health outcomes of recipients,” she argues. “A close examination of the ‘Swine Flu’ 2009 vaccine and the vaccine for human papillomavirus (HPV), intended to prevent cervical cancer, shows shortcomings in the evidence base and rationale for the vaccines. This investigation demonstrates that not all vaccines have been demonstrated to be safe, effective or necessary.”

The social sciences researcher called for “independent research” into the safety and efficacy of current vaccines, and added that it was important to have “comprehensive evidence that it is safe to combine multiple vaccines in the developing bodies of infants”.

Dr Yeatman said large-scale immunisation programs began in the 1930s and “immunisation provides an important safeguard against infectious disease when children go to school or play with others”.

According to Immunise Australia, mass immunisation had led to a 99 per cent plunge in deaths from vaccine-preventable disease.

“For more than 50 years, children have been immunised and it is one of our best success stories in public health,” she said.

Wollongong University has staunchly defended its decision to grant Dr Wilyman a PhD, on the grounds of academic freedom.

But, following sustained criticism, it has launched a review of the process involved in awarding PhDs – though it will not include that presented to Dr Wilyman.

Adrian Rollins

[Correspondence] Perinatal depressive symptoms preceded by mental health problems

Longitudinal research by George Patton and colleagues (Aug 29, p 875)1 suggests that early intervention for mental health issues in adolescence and young adulthood might prevent later occurrences of depression. Although the authors acknowledge the part that social disadvantage and intimate partner violence might play in development of depression, they fail to highlight the potential of early intervention with intimate partner violence.

News briefs

Touchbase website for LGBTI health

A new website has been developed to provide targeted information on drugs, alcohol, and mental and sexual health to Australia’s lesbian, gay, bisexual, transgendered and intersex communities, BuzzFeed Australia reports. TouchBase (www.touchbase.org.au) is a joint initiative between the Victorian AIDS Council, the Australian Federation of AIDS Organisations and the Australian Drug Foundation. A unique aspect of TouchBase is its focus on drug interactions with HIV medication and hormones. “We’ve created TouchBase to address gaps in existing information for LGBTI people,” said Victorian AIDS Council CEO Simon Ruth. “It’s a unique website, because LGBTI people have different drug-using norms — we use drugs in different patterns, we have different concerns, people have been dealing with different issues throughout their lives.”

New Surgeon-General for ADF

Air Vice-Marshal Tracy Smart has been named as the new Commander of Joint Health Command and Surgeon-General of the Australian Defence Force (ADF), taking over from Rear-Admiral Robyn Walker, who served in the role from 2011. Air Vice-Marshal Smart became the highest ranked lesbian officer in the ADF in 2009 when she was made Air Commodore in 2009. Her latest promotion will see her responsible for the delivery of health services and medical readiness of all ADF members, and will also provide strategic health advice and technical oversight of operational health services. She has publicly led the ADF contingent at the Sydney Gay and Lesbian Mardi Gras three times since 2008, the Star Observer reports. “One of the things that matter to me is to say gay men and lesbians are in every walk of life, including what in Australia now is a highly respected profession, like medicine and defence. The more people who do it the stronger that message is.”

Google searches track infectious diseases

The United States’ National Public Radio (NPR) reports that researchers from the University of Illinois in Chicago have teamed up with internet search giant Google to track sexually transmitted diseases. Google has given the researchers and the Centers for Disease Control and Prevention access to its search data. “Researchers can mine Google data to identify search terms that spiked during previous upticks in a particular disease. Then, researchers can measure the frequency of those searches in real time to estimate the number of emerging cases. For instance, a jump in gonorrhea might coincide with more people searching ‘painful urination’ or other symptoms. Search trends can be broken down by city and state, weighted by significance and combined with other data to produce a snapshot of where disease is spreading well before public health agencies report the number of verified cases.”

Vaccine for dengue fever approved in Mexico

The New York Times reports that Mexico has become the first country to approve the use of a vaccine to protect people aged 9–45 years against dengue fever. Clinical trials showed the vaccine reduced the risk of developing dengue by about 60%, the NYT reported. There is no treatment for dengue, a viral disease transmitted by mosquitoes. It can cause high temperature and intense joint and muscle pain. In severe cases, it can be fatal. Estimates about the number of people sickened by dengue each year range from 50 million to 400 million. In recent years, the disease has spread out of its traditional location in developing countries in tropical areas.

Almost two-thirds of Aussies overweight or obese

Australian Bureau of Statistics data released in the 2014–15 National Health Survey showed that 63.4% of Australians are classified as overweight or obese, totalling 11.2 million people. A quarter of children aged 5–17 years are overweight or obese. Nevertheless, 56.2% of Australians aged 15 years and over consider themselves to be in excellent or very good health. One in nine adults experienced high or very high levels of psychological stress. “The percentage of adults consuming more alcohol than the recommended guidelines — two standard drinks per day — dropped by 2% from 2011–12 to 17.4%”, the Huffington Post reports. “One in four men exceeded the lifetime risk guidelines compared to one in 10 women. Smoking rates among 18–44 year olds have declined by 12 percent since 2001. Rates of smoking are higher in outer regional and remote areas. Mental and behavioural conditions topped the major long-term health conditions list, with four million sufferers identified in 2014–15.”

Transforming Cochrane

If Cochrane were a car, some might see it as a beige 1995 Volvo station wagon; incredibly safe, magnificently reliable, but in need of an update. Cochrane has achieved a lot in the past 20 years: over 6500 reviews have been completed by a network of 30 000 contributors from 130 countries. We are recognised for the quality and rigour of our evidence syntheses, our leadership in methods development and our contribution to the world of evidence-based health care.

But, as we settle into our third decade, we also know that if Cochrane is going to thrive, we need to change. Our content needs to be more useable, timely and relevant, and delivered without compromising on quality. To achieve this, Cochrane is transforming how it goes about its work. We are investing in initiatives to bring people, processes and technology together that will maximise the value of our networks, improve how we conduct our reviews and provide new ways of using the data in Cochrane reviews.

Initiatives include using machine learning to reduce the time taken to retrieve research relevant to our reviews; crowdsourcing to increase the efficiency new research is screened and tagged; and online platforms that connect people who need help with their reviews with those who have the time and expertise to lend a hand.

Cochrane now has a dedicated online tool, Covidence, for managing several steps of the review process, from screening and selecting studies to assessing risk of bias and extracting data. This is making life easier for reviewers and ensures that all the effort that goes into producing reviews is captured in one place for all time.

The world of linked data holds great potential for data-rich organisations like Cochrane. We have developed tools to better annotate our reviews (and the study data buried within them) and to make these data more easily available to others, such as guideline producers. It also means we can enrich our own content by linking to relevant external data sources.

For more information, visit http://community.cochrane.org/transform and http://linkeddata.cochrane.org.

[Correspondence] Systematic reviews and research waste

Whether or not all available trials should be included in a meta-analysis has been debated for many years.1 Ian Roberts and Katharine Ker2 argue that systematic reviews increase waste in research by promoting underpowered trials. We disagree and argue that a systematic review is not wasteful if it includes small studies; underpowered trials might be acceptable if investigators use methodological rigor to eliminate bias, thoroughly report results to avoid misinterpretation, and always publish results to avoid publication bias.