Kathy Flitcroft

Communicating about screening

Informed choice is important for screening, but not everyone wants or is able to analyse research data. Vikki Entwistle and colleagues propose a new approach to communication

Getting evidence into policy: The need for deliberative strategies?

Getting evidence into policy is notoriously difficult. In this empirical case study we used document analysis and key informant interviews to explore the Australian federal governments policy to implement a national bowel cancer screening programme, and the role of evidence in this policy. Our analysis revealed a range of institutional limitations at three levels of national government: within the health department, between government departments, and across the whole of government. These limitations were amplified by the pressures of the 2004 Australian federal election campaign. Traditional knowledge utilisation approaches, which rely principally on voluntarist strategies and focus on the individual, rather than the institutional level, are often insufficient to ensure evidence-based implementation. We propose three alternative models, based on deliberative strategies which have been shown to work in other settings: review of the evidence by a select group of experts whose independence is enshrined in legislation and whose imprimatur is required before policy can proceed; use of an advisory group of experts who consult widely with stakeholders and publish their review findings; or public discussion of the evidence by the media and community groups who act as more direct conduits to the decision-makers than researchers. Such deliberative models could help overcome the limitations on the use of evidence by embedding public review of evidence as the first step in the institutional decision-making processes.

Increasing breast reconstruction rates by offering more women a choice

Breast reconstruction (BR) following mastectomy for breast cancer is safe and has high rates of patient satisfaction, yet only around 12% of Australian women undergo BR. This study presents BR rates and outcomes from a specialist practice that discusses reconstruction options with all women medically suitable for BR.

Patterns and outcomes of breast reconstruction in older women – A systematic review of the literature

PURPOSE Older age is associated with lower rates of breast reconstruction (BR) for women requiring mastectomy. The purpose was to assess the available evidence on uptake, outcome and quality of life (QoL) after BR in older women. METHODS A systematic literature review was performed via Medline, Embase and Cochrane databases using the search terms breast reconstruction, breast cancer, and mastectomy. Eligible studies reported rates of BR, rates of different reconstructive techniques, complication rates, and/or patient reported outcome measures (PROMs) of BR in women aged 60 years or older undergoing mastectomy for ductal carcinoma in situ or invasive carcinoma. RESULTS A total of 42 eligible studies were included, with 32 of these reporting BR rates, 10 reporting rates of different reconstructive techniques, 10 reporting rates of complications, and four reporting PROMs. The studies reported 24,746 cases of BR in 407,570 mastectomy patients aged 60 years or older from 1987 to 2012. Implant based BR was more common than autologous techniques. Mostly, complication rates were not higher in older women, and QoL outcomes were similar to younger women. CONCLUSIONS This review confirms that BR rates are lower in older women despite recent studies demonstrating its efficacy. The perception among some surgeons and women requiring mastectomy that the potential risks of BR in older women outweigh the benefits needs to be revisited. Education of consumers and surgeons along with public advocacy for offering BR to all clinically eligible women are the most promising means of changing practice.

Colorectal cancer screening: Why immunochemical fecal occult blood tests may be the best option

BackgroundThere are many test options available for colorectal cancer screening. The choice of test relates to the objectives of those offering or considering screening.DiscussionWhile all screening programs aim to detect disease early in order to improve the length and/or quality of life for the individual, some organizations and individuals prefer screening tests that offer the opportunity for cancer prevention. Others favor maximizing participation or the opportunity for shared decision-making, including discussion of information on test quality and availability. We propose three additional objectives for screening: minimizing harms, optimizing economic efficiency and maximizing equity of access to screening.SummaryApplying these objectives to colorectal cancer screening, we advocate the use of immunochemical FOBTs as the preferred screening strategy, as it satisfies all three of these important objectives.

Utility of neoadjuvant chemotherapy in the treatment of operable breast cancer

Neoadjuvant chemotherapy (NAC) is a legitimate alternative to first‐line surgical therapy for the treatment of breast cancer patients, as level one evidence shows the effect on overall survival is equivalent to that of adjuvant chemotherapy. In the treatment of women with operable breast cancer, NAC provides a number of potential advantages including: improving the chance of achieving breast‐conserving surgery, improving cosmesis after breast‐conserving surgery, downstaging the breast and axilla, allowing time to fully consider surgical options, time for genetic testing and facilitating breast reconstruction in otherwise high‐risk patients. However, in Australia, NAC is poorly utilized with less than 3% of women with operable breast cancer receiving NAC. This review discusses the potential harms and benefits of NAC, discusses areas of controversy in the use of NAC and describes how we have used NAC in our own practice. We conclude that if it is obviously necessary for the newly presenting breast cancer patient to have chemotherapy as part of the treatment, it is worth considering NAC. In many patients, the potential benefits of NAC outweigh the harms. However, maximizing these benefits is closely aligned with appropriate patient selection and timely multidisciplinary team communication.

An evaluation of factors affecting preference for immediate, delayed or no breast reconstruction in women with high-risk breast cancer.

Women with locally advanced breast cancer face many conflicting issues affecting their choice of immediate versus delayed versus no breast reconstruction (BR). This single‐centre pilot study assessed high‐risk womens reasons and priorities in choosing the timing and type of BR in a setting where all clinically feasible options were discussed with all women.

A comparative case study of bowel cancer screening in the UK and Australia: evidence lost in translation?

Objectives (i) To document the current state of the English, Scottish, Welsh, Northern Irish and Australian bowel cancer screening programmes, according to seven key characteristics, and (ii) to explore the policy trade-offs resulting from inadequate funding. Setting United Kingdom and Australia. Methods A comparative case study design using document and key informant interview analysis. Data were collated for each national jurisdiction on seven key programme characteristics: screening frequency, population coverage, quality of test, programme model, quality of follow-up, quality of colonoscopy and quality of data collection. A list of optimal features for each of the seven characteristics was compiled, based on the FOBT screening literature and our detailed examination of each programme. Results Each country made different implementation choices or trade-offs intended to conserve costs and/or manage limited and expensive resources. The overall outcome of these trade-offs was probable lower programme effectiveness as a result of compromises such as reduced screening frequency, restricted target age range, the use of less accurate tests, the deliberate setting of low programme positivity rates or increased inconvenience to participants from re-testing. Conclusions Insufficient funding has forced programme administrators to make trade-offs that may undermine the potential net population benefits achieved in randomized controlled trials. Such policy compromise contravenes the principle of evidence-based practice which is dependent on adequate funding being made available.

Making decisions about breast reconstruction: A systematic review of patient-reported factors influencing choice

PurposeMany studies have explored women’s reasons for choosing or declining a particular type of breast reconstruction (BR) following mastectomy for breast cancer. This systematic review synthesises women’s reasons for choosing a range of BR options, including no BR, in different settings and across time.MethodsThirteen databases were systematically searched, with 30 studies (4269 participants), meeting the selection criteria. Information on study aim and time frame, participation rate, design/methods, limitations/bias, reasons and conclusions, as well as participant clinical and demographic information, was reported. An overall quality score was generated for each study. Reasons were grouped into eight domains.ResultsWhile study methodology and results were heterogeneous, all reported reasons were covered by the eight domains: Feeling/looking normal; Feeling/looking good; Being practical; Influence of others; Relationship expectations; Fear; Timing; and Unnecessary. We found a strong consistency in reasons across studies, ranging from 52% of relevant publications citing relationship expectations as a reason for choosing BR, up to 91% citing fear as a reason for delaying or declining BR. Major thematic findings were a lack of adequate information about BR, lack of genuine choice for women and additional access limitations due to health system barriers.ConclusionsUnderstanding women’s reasons for wanting or not wanting BR can assist clinicians to help women make choices most aligned with their individual values and needs. Our thematic findings have equity implications and illustrate the need for surgeons to discuss all clinically appropriate BR options with mastectomy patients, even if some options are not available locally.

Incorporating evidence and politics in health policy: Can institutionalising evidence review make a difference?

Much of the evidence translation literature focuses narrowly on the use of evidence in the initial policy formulation stages, and downplays the crucial role of institutions and the inherently political nature of policy making. More recent approaches acknowledge the importance of institutional and political factors, but make no attempt to incorporate their influence into new models of evidence translation. To address this issue, this article uses data from a comparative case study of bowel cancer screening policy in Australia, the United Kingdom and New Zealand, to propose alternative models of evidence incorporation which apply to all stages of the policy process.