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Preference: Women's Health

Breast screening in Australia: more harm than good?

 

Findings from two new NSW studies point to substantial overdiagnosis of early breast cancer and suggest screening may in some cases be causing more harm than benefit.

The studies, authored by researchers from the Universities of Sydney and New South Wales, looked at data from all women in New South Wales who received a breast cancer diagnosis from 1972 to 2012, spanning both the pre-screening and screening years.

One study, which tracked diagnoses of ductal carcinoma in situ (DCIS), saw a 100-fold increase from 0.5 to 16.8 cases per 100,000 women over the period. It found that DCIS incidence has continued to rise despite screening being now well established for over two decades.

The second study, looking at cancer stage at diagnosis, found that the incidence of all stages of breast cancer has increased over the past 40 years, with the greatest rise occurring during the screening era in women aged 50-69 years.

The researchers say that since the purpose of screening is to detect early disease in order to prevent later metastases, it would be logical to see some reduction in advanced disease as screening numbers stabilised.

But that’s not what the figures show. While many more women are being diagnosed and treated for DCIS and early disease, this is not preventing later stage disease and associated metastases.

“Our findings suggest that some of the expected benefits of screening may not have been realised and are consistent with overdiagnosis,” the authors write.

“That distant metastases do not appear to be affected by mammography is a concern given prevention of advanced disease is a key aim of screening, along with breast cancer mortality.”

What may be happening, the authors suggest, is that most of these early breast cancers now being picked up through screening would never have developed into fatal disease had they gone undiagnosed, or would have developed so slowly that older women would have been more likely to die of something else first.

And the result is that while many more women are being diagnosed and treated for DCIS and early disease, this is not preventing later stage disease.

Incidence rates of DCIS continued to rise even after the number of women being screened stabilised, the researchers found. This may be due to a switch from film to the more sensitive digital mammography, as well as other technological advances in diagnosis, including breast ultrasound, MRO and tomosynthesis.

Currently all women diagnosed with DCIS receive treatment, and there is also a trend towards more aggressive treatment such as contralateral mastectomies. The authors warn that the risk of overtreatment is “substantial, with serious effects on quality of life”.

“Our findings suggest that we should rethink strategies for the detection and management of DCIS,” they write. Their findings “lend support to trials evaluating de-escalation of therapy for certain types of early-stage breast cancer, such as DCIS”.

While it’s true that breast cancer mortality rates have dropped considerably over the period studied, the authors say this may be primarily due to improved treatment options rather than screening.

Screening in NSW has been free for women since 1988, and since 1991 women aged 50-69 have been targeted with letters of invitation.

You can access the two studies here and here.

Why we desperately need more focus on gynaecological cancers

 

A woman’s reproductive system has been called many names, yet still remains a taboo topic.

For many women the words vagina, vulva, uterus, cervix and ovary are not spoken. Rather, euphemisms like “down there”, or “down below” are used. It’s time to start talking about ‘The box’.

The taboo

Talking about our genitalia, and particularly women’s genitalia, is culturally taboo. There are a lot of people who wrongly believe that being diagnosed with a gynaecological cancer means a woman is ‘loose’ or ‘dirty’.

It’s hard to start a conversation about your gynaecological health in the face of such taboos and critical judgment. This discomfort is costing the lives of our mothers, daughters, sisters and friends.

This year 5500 women will be diagnosed with a gynaecological cancer. In the past 25 years overall cancer survival in Australia improved by 19%, but gynaecological cancer survival improved by just 7%.

The Australia New Zealand Gynaecological Oncology Group (ANZGOG) is conducting and promoting cooperative clinical trials and multidisciplinary research to improve the lives of women who have gynaecological cancer.

September is International Gynaecological Cancer Awareness Month, and an important opportunity to raise awareness of gynaecological cancers. ANZGOG’s Save the Box campaign aims to raise awareness and funds for gynaecological cancer research.

Gynaecological cancer symptoms

There are seven types of gynaecological cancer: endometrial, ovarian, cervical, vaginal, vulvar, and two rare pregnancy-related cancers.

The symptoms of gynaecological cancer are vague but include:

  • Abdominal bloating
  • Feeling full
  • Increased frequency in urination or bowel movements
  • Menstrual irregularities
  • Indigestion
  • Fatigue
  • Itching, burning or soreness
  • Lumps, sores or wart-like growths
  • Pain during sexual intercourse
  • Bleeding after menopause

If a woman is experiencing any of these symptoms and they are unusual for her or persistent, she should see her GP. If she is diagnosed with a gynaecological cancer, she should be referred to a Gynaecological Oncologist – see the Australian Society for Gynaecologic Oncologists for a full directory. Statistics indicate that women diagnosed with a gynaecological cancer have the best survival outcomes if they are referred to a gynaecological oncologist and managed as part of a multidisciplinary team.

Perhaps because of the taboos, and also because of the vagueness of some of the symptoms, it can take several visits to the GP before a diagnosis of a gynaecological cancer is suspected and appropriate referral made. Many women who have vulval or vaginal cancers have had symptoms that they’ve been embarrassed about and this has delayed them going to the GP.

Current trends in gynaecological cancer

Endometrial

We are seeing an increased incidence of endometrial cancer as a result of the growing obesity epidemic.

Endometrial cancer is a preventable disease in 4 out of 10 patients through exercise or diet. Women can be referred by their GP’s via an Enhanced Primary Care (EPC) referral to an ESSA accredited exercise physiologist for 5 Medicare reimbursed sessions.

Ovarian

A woman diagnosed with ovarian cancer has only a 40% chance of surviving five years from her diagnosis. Survival has not improved in decades and lags well behind breast (89% survival five years from diagnosis) and other cancers.

New genomic knowledge has radically changed the way we view ovarian cancer. The disease is now classified into seven molecular subtypes, some of which are very rare. We now understand why a one size-fits-all approach to treatment must and can change.

The ANZGOG Ovarian Cancer Alliance for Signal-Seeking Research (OASIS) initiative has been created to catalyse and fund research into improved treatments for ovarian cancer that target the seven molecular subtypes.

Cervical

On a positive note, with the introduction of the cervical cancer vaccine, the incidence of cervical cancer is predicted to fall dramatically, although this may not be evident for 10 to 20 years. The new cervical screening program, with the emphasis on HPV testing, is also predicted to reduce the incidence of cervical cancer..

The future

Government funding of research is increasingly competitive, meaning that early career researchers, pilot studies, and research into rarer diseases like gynaecological cancers are missing out.

As a non-profit organisation, ANZGOG continues to struggle with funding. Clinical trials are costly and this is the major barrier we face in opening new trials and expanding our clinical trial portfolio.

Why does research matter? Because research leads to improved outcomes through better treatments, better survival and better quality of life.

We’ve seen tremendous advances in the survival rates of women who have breast cancer and many of those improvements are the result of research. Virtually every advance in cancer survival has been made on the back of clinical trials.

The current growth in the development and use of targeted therapies will have a substantial impact. The upcoming challenge will be how to incorporate these drugs effectively into the treatment for ovarian cancer (and perhaps other cancers in the future) in a way that is of greatest benefit to patients.

ANZGOG’s Survivors Teaching Students® – Saving Women’s Lives program brings the faces and voices of ovarian cancer survivors and their caregivers into the classrooms of medical and nursing students. Survivors, through their own personal experiences, are in a unique position to help students become more sensitive to the risk factors associated with ovarian cancer and symptoms of ovarian cancer. Our goal is to increase the number of health care providers who recognise the risk factors and symptoms of ovarian cancer, in the hope that women can be diagnosed earlier, when cure rates are higher.

While many endometrial cancers are cured with surgery alone, there are plenty of unanswered questions about the extent of surgery needed for early endometrial cancer patients, and what additional treatment may be best for those with more advanced disease. ANZGOG is conducting a surgical trial, STATEC, to try to determine the extent of surgery that is best for patients with apparent early stage, but high risk, endometrial cancer.

The improvements in breast cancer survival rates are the shining example of what can happen when we openly talk about the problems, and provide the funds needed to save lives.

‘Save the Box’ is fundraising for gynaecological cancer research conducted by the Australia New Zealand Gynaecological Oncology Group (ANZGOG). Find out more or make a donation today at https://www.savethebox.org.au/

Associate Professor Alison Brand

Alison is Chair of the Australia New Zealand Gynaecological Oncology Group and Director of Gynaecologic Oncology at Westmead Hospital

[Comment] Offline: NCDs—why are we failing?

Why is the global health community failing to respond effectively to the rising burden of non-communicable diseases (NCDs)? The answer can be summed up in one word—fear. Fear of a species-threatening pandemic. A pervasive fear that has displaced all other health concerns. Anxiety among political elites is causing a recalibration of priorities among global health leaders. In his first speech to staff in Geneva this month, WHO’s new Director-General, Tedros Adhanom Ghebreyesus, named four urgent issues: health emergencies; universal health coverage; women’s, children’s, and adolescents’ health; and climate change.

[Viewpoint] The medical education system in Israel

During the British administration of the Palestine Mandate, before the foundation of Israel in 1948, the Jewish community built hospitals, developed a network of clinics, and established a fairly extensive coverage of health care.1 Yet not until 1949 was the first medical school founded at the Jerusalem-based Hebrew University of Jerusalem. Although much of the funding came from the Hadassah, the Women’s Zionist Organization of America, most of the teaching staff were, at first, refugees who had received their medical training in Germany before migrating to Palestine.

[Viewpoint] Women and health in Israel

WHO defines health as “a complete state of physical, mental and social wellbeing, and not merely the absence of disease or infirmity”.1 This broad definition includes physical and mental health, but also socioeconomic standing and access to resources such as health care and safety. In this Viewpoint, we present a holistic picture of women’s health within the Israeli societal and cultural context, taking these factors into account.

Medical role models honoured at AMA National Conference

AMA Woman in Medicine

Dr Genevieve Goulding, an anaesthetist with a strong social conscience and a passion for doctors’ mental health and welfare, has been named the AMA Woman in Medicine for 2017.

Described by her colleagues as a quiet achiever, ANZCA’s fourth successive female President, Dr Goulding has used her term to focus on professionalism, workforce issues, advocacy, and strengthening ANZCA services for Fellows and trainees.

Dr Goulding is a founding member of the Welfare of Anaesthetists Group, which raises awareness of the many personal and professional issues that can affect the physical and emotional wellbeing of anaesthetists throughout their careers.

Dr Michael Gannon, who presented the award at the AMA National Conference, said that Dr Goulding was a role model for all in the medical profession.

“She has raised the profile and practice of safe and quality anaesthesia. She is committed to ensuring patients – no matter their background or position – can rely on and benefit from our health system,” Dr Gannon said.

Dr Goulding continues to effect change with her work on the ANZCA Council and on the Queensland Medical Board, her numerous positions with the Australian Society of Anaesthetists, and her current work with the Anaesthesia Clinical Committee of the MBS Review.

Excellence in Healthcare Award

This year, AMA recognised a true medical leader Dr Denis Lennox, who has made an outstanding contribution to rural and remote health care in Queensland, and to the training of rural doctors.

Dr Lennox has had an extraordinary career since starting as a physician and medical administrator in his home town of Bundaberg in the 1970s. 

Dr Gannon said that Dr Lennox had earned this award through his vision and revolutionary training of rural general practitioners and specialist generalists.

“Dr Lennox has been responsible for real workforce and healthcare improvements in all parts of Queensland, particularly through the Queensland Rural Generalist Program which has delivered more than 130 well-prepared Fellows and trainees into rural practice across Queensland since 2005 – an incredible achievement,” Dr Gannon said when presenting the award.

An Adjunct Associate Professor at James Cook University and Executive Director of Rural and Remote Medical Support at Darling Downs Hospital Health Service, Dr Lennox prepares to retire from 40 years of public service.

AMA Women’s Health Award

A nurse and midwife in Darwin, Eleanor Crighton has been awarded the Women’s Health Award – an award that goes to a person or group, not necessarily a doctor or female, who has made a major contribution to women’s health.

Ms Crighton won the award for her outstanding commitment to Indigenous women’s health. 

Dr Gannon when presenting the award to Ms Crighton said that she had made a real difference to the lives of Aboriginal women in the greater Darwin region through them gaining access to affordable family planning.

“As an obstetrician, I know the importance of the work of women’s health teams, particularly in Aboriginal community-controlled organisations like Danila Dilba,” Dr Gannon said.

As the Women’s Health Team leader at Danila Dilba Health Service, Ms Crighton has shown her commitment to Indigenous health by pursuing additional studies and gaining personal skills with the aim of filling gaps in health care services.

Ms Crighton has also worked tirelessly to raise awareness of Fetal Alcohol Spectrum Disorder, and has started training Danila Dilba’s first home-grown trainee midwife, at the same time as pursuing her own Nurse Practitioner studies. 

Meredith Horne 

13 Reasons Why – suicide the last taboo

13 Reasons Why is a Netflix TV drama about a troubled teenager who takes her own life, having beforehand recorded 13 tapes explaining the ‘reasons’ for her suicide. The show is based on ayoung adult best-selling novel by Jay Asher.

This TV show has generated controversy over its theme of teen suicide, depicting suicide ‘method’, and the graphic depiction of rape. Debate on the program content, and the reaction from suicide prevention and mental health organisations, has created an international furor. Headspace, the National Youth Mental Health Foundation providing early intervention mental health services to 12-25 year olds, issued a warning about the show’s “dangerous content” and labelled the program irresponsible for depicting suicide methods. Headspace said it “exposes viewers to risky suicide content and may lead to a distressing reaction by the viewer, particularly if the audience is children and young people.” A critic on MamaMia, Australia’s largest independent women’s website, described the show as “a suicide manual”.

Other critics point out that 13 Reasons Why does not conform to the guidelines on safe and responsible reporting on suicide. Mindframe, who provide information to support the reporting, portrayal and communication of suicide, said the TV drama “sends the wrong messages about suicide risk and the show does nothing to encourage help-seeking.”

There is no question that 13 Reasons Why is confronting viewing; with graphic messages and imagery of suicide methods. Most troubling for many suicide and mental health experts, it does not present options for troubled teens. This is the view of leading cultural magazine Rolling Stone: “Had 13 Reasons Why showcased other forms of outreach, like therapy, teens watching it might realize that there is always an option that doesn’t include self-harm.”

In a Vanity Fair interview, scriptwriter Nic Sheff (who incidentally has spoken of his own suicide attempts) defended the show’s direct approach: “Facing [suicide] head-on … will always be our best defense against losing another life. We need to keep talking, keep sharing, and keep showing the realities of what teens in our society are dealing with every day. To do anything else would be not only irresponsible, but dangerous.”

Many websites discussing the pros and cons of this controversial series agree that it is leading to a wider discussion about teenage issues and how parents can talk with the children about suicide and self-harm. The Sydney Morning Herald reviewer described the show as an “unflinching but unexploitative portrayal … 13 Reasons Why is extremely tough viewing at times … It’s strong stuff that works hard to shatter pernicious assumptions.” The New York Times commented: “The overall message — one that probably appeals to teenagers — is that it’s possible to figure out why someone takes her own life, and therefore to guard against it happening to others.” The Guardian, by contrast, deplored the series as “horrifying”. The New Yorker, in a scathing assessment, raised a crucial issue, namely that the series does not address mental illness, and presents “suicide as both an addictive scavenger hunt and an act that gives … glory, respect, and adoration that was denied in real life.”

The debate over 13 Reasons Why is, in essence, whether teenage suicide is a subject matter to be graphically depicted in a popular teen drama, whether the modern appetite for ‘binge’ watching allows young viewers to properly understand and discuss the issues (and seek appropriate counseling and guidance), and whether a slick, glossy TV series can inadvertently present suicide as ‘normal’, even glamorous.

Conversely, as others have advanced, we shouldn’t make suicide, especially youth suicide, a taboo issue. By bringing it out into the open (and the show is based on a popular book that caused few ripples when it was released) we open a gateway into a most confronting and all too real issue for young people.

It’s too early to assess the impact of this show on young viewers, but it does appear that how we discuss youth suicide has been changed.

Simon Tatz
Director, Public Health   

[Comment] The Global Financing Facility—towards a new way of financing for development

There are many uncertainties in global health. Major policy changes risk affecting women’s reproductive health, internal displacement and refugee crises are raging in many parts of the world, and weak public health systems are not readily responsive to emerging health threats. Many countries face fragility, conflict, and economic upheavals. But there is also inspiration and hope in the amazing resilience of communities, as seen in post-Ebola west African countries, and in the power of voice and collective action among informed citizens who are advocating for sexual and reproductive health and rights for all women.

[Editorial] Prospects for neonatal intensive care

In today’s Lancet we publish a clinical Series on neonatal intensive care in higher resource settings. The Series, led by Lex Doyle from The Royal Women’s Hospital in Melbourne, VIC, Australia, includes new approaches to the old nemesis of bronchopulmonary dysplasia (which still affects up to 50% of infants born before 28 weeks’ gestation), discusses the delicacy of fine-tuning interventions in response to evolving evidence, and explores the frontier of nutritional research by referring to preterm birth as a nutritional emergency.