Margaret Staples

Trends in the incidence of non-melanocytic skin cancer (NMSC) treated in Australia 1985–1995: Are primary prevention programs starting to have an effect?

Non‐melanocytic skin cancer (NMSC) is the most common cancer in Australia, but data on its incidence are not routinely collected by cancer registries. National surveys were conducted in 1985, 1990 and 1995 to estimate NMSC incidence. Trends in incidence between 1985 and 1995 have been examined to determine the impact of primary prevention campaigns aimed at controlling skin cancer in Australia. National random household surveys of Australians aged over 13 years were used to estimate NMSC incidence in 1985, 1990 and 1995. Age‐ and sex‐specific rates by survey year were modelled using Poisson regression. Basal cell carcinoma (BCC) rates in 1995 were 788 per 100,000, an increase of 19% since 1985. Squamous cell carcinoma (SCC) rates rose by 93% over the same period, from 166 to 321 per 100,000. The ratio of BCC:SCC changed from 4:1 in 1985 to 2.5:1 in 1995. BCC rates in latitudes <29°S remained at about 3 times those in latitudes >37°S over the decade. The ratio of SCC incidence between these latitudes changed from around 7:1 to 3:1 over the same period. Although NMSC incidence rates continue to rise, there have been reductions in BCC observed in younger age groups. Incidence rates of NMSC continue to rise in Australia, but there is evidence of a reduction in BCC incidence in younger cohorts. This is evidence that public health campaigns to reduce sun exposure may be having a beneficial effect on skin cancer rates. Int. J. Cancer 78:144–148, 1998.© 1998 Wiley‐Liss, Inc.

Has mortality from melanoma stopped rising in Australia? Analysis of trends between 1931 and 1994.

Abstract Objective: To describe recent trends in mortality from melanoma in Australia. Design: An analysis of trends in age standardised and age and sex specific mortalities by year of death and median year of birth (cohort). Setting: Australia. Subjects: All deaths from melanoma registered in Australia between 1931 and 1994. Results: Melanoma mortality rose steadily from 1931 to 1985. From 1959 the annual rate of increase was 6.3% in men and 2.9% in women, resulting in mortalities of 4.82 and 2.51 per 100000 person years in 1985 and 1989, respectively. Mortalities for both sexes seem to have plateaued from June 1985 onwards. In 1990-4 the rate rose by 3.7% in men to 5.00 per 100000 and in women it fell by 5.2% to 2.38 per 100000. The non-significant increase after 1985 in mortality in men was restricted to those aged over 70 years of age, whereas the fall in rates in women was mostly in those aged under 55 years. This pattern was generally reflected in the state trends, though with some variation: rates for women in Queensland had peaked in the late 1970s; while rates for men in New South Wales continued to rise in 1990-4, placing them above those for Queensland. Examination of mortalities specific for age, period, and cohort for Australia as a whole showed several salient features. Rates in men rose steeply in cohorts born before about 1930; were stable in cohorts born between 1930 and 1950; and fell in more recent cohorts. Rates in women showed similar changes but about five years earlier. Conclusion: Melanoma mortality in Australia peaked in about 1985 and has now plateaued. On the basis of trends in cohorts it can be expected to fall in coming years. Key messages Key messages On the basis of cohort trends up to 1977 previ- ous analysis predicted that melanoma mortality would not reach its peak before 2010 Mortality, however, peaked in around 1985 and is now falling in women Variation in this trend between states underlines the need to evaluate the cost effectiveness of differ- ent strategies to promote early detection

Plasma Lysophosphatidylcholine Levels Are Reduced in Obesity and Type 2 Diabetes

Background Obesity and type 2 diabetes (T2DM) are associated with increased circulating free fatty acids and triacylglycerols. However, very little is known about specific molecular lipid species associated with these diseases. In order to gain further insight into this, we performed plasma lipidomic analysis in a rodent model of obesity and insulin resistance as well as in lean, obese and obese individuals with T2DM. Methodology/Principal Findings Lipidomic analysis using liquid chromatography coupled to mass spectrometry revealed marked changes in the plasma of 12 week high fat fed mice. Although a number of triacylglycerol and diacylglycerol species were elevated along with of a number of sphingolipids, a particularly interesting finding was the high fat diet (HFD)-induced reduction in lysophosphatidylcholine (LPC) levels. As liver, skeletal muscle and adipose tissue play an important role in metabolism, we next determined whether the HFD altered LPCs in these tissues. In contrast to our findings in plasma, only very modest changes in tissue LPCs were noted. To determine when the change in plasma LPCs occurred in response to the HFD, mice were studied after 1, 3 and 6 weeks of HFD. The HFD caused rapid alterations in plasma LPCs with most changes occurring within the first week. Consistent with our rodent model, data from our small human cohort showed a reduction in a number of LPC species in obese and obese individuals with T2DM. Interestingly, no differences were found between the obese otherwise healthy individuals and the obese T2DM patients. Conclusion Irrespective of species, our lipidomic profiling revealed a generalized decrease in circulating LPC species in states of obesity. Moreover, our data indicate that diet and adiposity, rather than insulin resistance or diabetes per se, play an important role in altering the plasma LPC profile.

Psychological Consequences of Screening Mammography

Objective- To examine the psychological consequences at a number of stages in the screening process for women attending a screening mammography programme. Setting- A pilot mammographic screening programme in Melbourne, Australia. Method — The psychological consequences questionnaire (PCQ; a reliable and valid measure of the psychological consequences of screening mammography) was used to measure the emotional, social, and physical functioning of women in a mammographic screening programme and a control community sample. A screening group (in whom no abnormality was detected at initial screen; n=142) had four measurements: at screening clinic; before results were received; one week after all-clear results were received; and eight months after initial visit. The recall group (who were recalled for further investigation which showed the detected abnormality to be benign; n = 58) had measurements at the same points as the screening group and an additional measurement while waiting at the recall assessment clinic. A randomly selected community control group (n = 52) had measurements one week, two weeks, three weeks; and eight months after consenting to participate. Results - Emotional, social, and physical functioning of women in the screening group did not change over time and at no point differed significantly from that of community controls. The profiles of emotional and physical dysfunction of women in the recall group differed significantly from those of the screening and control groups. The level of emotional and physical dysfunction in the recall group was highest while waiting at recall assessment clinic, and scores were still significantly higher than scores obtained at comparable times from screening and control groups one week after obtaining notification that there was no sign of cancer (emotional P< 0·001; physical P < 0·05). This difference had disappeared eight months after the screening visit, when the level of emotional and physical functioning was similar to that of the screening and control groups. Social dysfunction scores did not change significantly over time and were similar for all three groups. Conclusions - Given that up to 10% of women are recalled for further investigations on first round screening, significant numbers of women may have psychological consequences. This speaks for the necessity for accurate reading of mammograms to minimise the false positive recall rate, and for counselling services to be available at recall assessment centres.

Up to a quarter of the Australian population may have suboptimal health literacy depending upon the measurement tool: results from a population-based survey

The objective of this paper is to measure health literacy in a representative sample of the Australian general population using three health literacy tools; to consider the congruency of results; and to determine whether these assessments were associated with socio-demographic characteristics. Face-to-face interviews were conducted in a stratified random sample of the adult Victorian population identified from the 2004 Australian Government Electoral Roll. Participants were invited to participate by mail and follow-up telephone call. Health literacy was measured using the Rapid Estimate of Adult Literacy in Medicine (REALM), Test of Functional Health Literacy in Adults (TOFHLA) and Newest Vital Sign (NVS). Of 1680 people invited to participate, 89 (5.3%) were ineligible, 750 (44.6%) were not contactable by phone, 531 (32%) refused and 310 (response rate 310/1591, 19.5%) agreed to participate. Compared with the general population, participants were slightly older, better educated and had a higher annual income. The proportion of participants with less than adequate health literacy levels varied: 26.0% (80/308) for the NVS, 10.6% (51 33/310) for the REALM and 6.8% (21/309) for the TOFHLA. A varying but significant proportion of the general population was found to have limited health literacy. The health literacy measures we used, while moderately correlated, appear to measure different but related constructs and use different cut offs to indicate poor health literacy.

Impact of dermoscopy and short-term sequential digital dermoscopy imaging for the management of pigmented lesions in primary care: a sequential intervention trial

Background  Studies have shown the benign to malignant ratio of excised pigmented skin lesions is suboptimal in primary care.

Segregation Analyses of 1,476 Population-Based Australian Families Affected by Prostate Cancer

Segregation analyses aim to detect genetic factors that have a major effect on an individuals risk of disease and to describe them in terms of mode of inheritance, age-specific cumulative risk (penetrance), and allele frequency. We conducted single- and two-locus segregation analyses of data from 1,476 men with prostate cancer diagnosed at age <70 years and ascertained through population registries in Melbourne, Sydney, and Perth, Australia, and from their brothers, fathers, and both maternal and paternal lineal uncles. Estimation and model selection were based on asymptotic likelihood theory and were performed through use of the software MENDEL. All two-locus models gave better fits than did single-locus models, even if lineal uncles were excluded or if we censored data (age and disease status) for relatives at 1992, when prostate-specific-antigen testing started to have a major impact on the incidence of prostate cancer in Australia. Among the genetic models that we considered, the best-fitting ones included a dominantly inherited increased risk that was greater, in multiplicative terms, at younger ages, as well as a recessively inherited or X-linked increased risk that was greater, in multiplicative terms, at older ages. The recessive and X-linked effects were strongly confounded, and it was not possible to fit them together. Penetrance to age 80 years was approximately 70% (95% confidence interval [CI] 57%-85%) for the dominant effect and virtually 100% for the recessive and X-linked effects. Approximately 1/30 (95% CI 1/80-1/12) men would carry the dominant risk, and 1/140 (95% CI 1/220-1/90) would carry the recessive risk or 1/200 (95% CI 1/380-1/100) would carry the X-linked risk. Within discussed limitations, these analyses confirm the genetic heterogeneity, of prostate cancer susceptibility, that is becoming evident from linkage analyses, and they may aid future efforts in gene discovery.

Effectiveness of vertebroplasty using individual patient data from two randomised placebo controlled trials: meta-analysis

Objective To determine whether vertebroplasty is more effective than placebo for patients with pain of recent onset (≤6 weeks) or severe pain (score ≥8 on 0-10 numerical rating scale). Design Meta-analysis of combined individual patient level data. Setting Two multicentred randomised controlled trials of vertebroplasty; one based in Australia, the other in the United States. Participants 209 participants (Australian trial n=78, US trial n=131) with at least one radiographically confirmed vertebral compression fracture. 57 (27%) participants had pain of recent onset (vertebroplasty n=25, placebo n=32) and 99 (47%) had severe pain at baseline (vertebroplasty n=50, placebo n=49). Intervention Percutaneous vertebroplasty versus a placebo procedure. Main outcome measure Scores for pain (0-10 scale) and function (modified, 23 item Roland-Morris disability questionnaire) at one month. Results For participants with pain of recent onset, between group differences in mean change scores at one month for pain and disability were 0.1 (95% confidence interval −1.4 to 1.6) and 0.2 (−3.0 to 3.4), respectively. For participants with severe pain at baseline, between group differences for pain and disability scores at one month were 0.3 (−0.8 to 1.5) and 1.4 (−1.2 to 3.9), respectively. At one month those in the vertebroplasty group were more likely to be using opioids. Conclusions Individual patient data meta-analysis from two blinded trials of vertebroplasty, powered for subgroup analyses, failed to show an advantage of vertebroplasty over placebo for participants with recent onset fracture or severe pain. These results do not support the hypothesis that selected subgroups would benefit from vertebroplasty.

Efficacy of standardised manual therapy and home exercise programme for chronic rotator cuff disease: randomised placebo controlled trial.

Objective To investigate the efficacy of a programme of manual therapy and exercise treatment compared with placebo treatment delivered by physiotherapists for people with chronic rotator cuff disease. Design Randomised, participant and single assessor blinded, placebo controlled trial. Setting Metropolitan region of Melbourne, Victoria, Australia. Participants 120 participants with chronic (>3 months) rotator cuff disease recruited through medical practitioners and from the community. Interventions The active treatment comprised a manual therapy and home exercise programme; the placebo treatment comprised inactive ultrasound therapy and application of an inert gel. Participants in both groups received 10 sessions of individual standardised treatment over 10 weeks. For the following 12 weeks, the active group continued the home exercise programme and the placebo group received no treatment. Main outcome measures The primary outcomes were pain and function measured by the shoulder pain and disability index, average pain on movement measured on an 11 point numerical rating scale, and participants’ perceived global rating of overall change. Results 112 (93%) participants completed the 22 week trial. At 11 weeks no difference was found between groups for change in shoulder pain and disability index (3.6, 95% confidence interval −2.1 to 9.4) or change in pain (0.7, −0.1 to 1.5); both groups showed significant improvements. More participants in the active group reported a successful outcome (defined as “much better”), although the difference was not statistically significant: 42% (24/57) of active participants and 30% (18/61) of placebo participants (relative risk 1.43, 0.87 to 2.34). The active group showed a significantly greater improvement in shoulder pain and disability index than did the placebo group at 22 weeks (between group difference 7.1, 0.3 to 13.9), although no significant difference existed between groups for change in pain (0.9, −0.03 to 1.7) or for the percentage of participants reporting a successful treatment outcome (relative risk 1.39, 0.94 to 2.03). Several secondary outcomes favoured the active group, including shoulder pain and disability index function score, muscle strength, interference with activity, and quality of life. Conclusion A standardised programme of manual therapy and home exercise did not confer additional immediate benefits for pain and function compared with a realistic placebo treatment that controlled for therapists’ contact in middle aged to older adults with chronic rotator cuff disease. However, greater improvements were apparent at follow-up, particularly in shoulder function and strength, suggesting that benefits with active treatment take longer to manifest. Trial registration Clinical trials NCT00415441.

Metastases from Squamous Cell Carcinoma of the Skin in Southern Australia

BACKGROUND The frequency with which squamous cell carcinoma (SCC) of the skin metastasizes is a matter of dispute. Studies from private practices have reported much lower rates than hospital-based surveys, and one school of thought is that SCCs which arise in sun-damaged skin have a low risk of metastasis. METHODS A prospective study of out-patients with histologically confirmed SCC was undertaken in southern Australia, a region with a very high incidence of skin cancer. RESULTS Between November 1988 and November 1989, 481 patients were entered into the study and 420 followed for at least 3 years. An SCC was the initial diagnosis for 73 patients, 3 were immunosuppressed and 2 had an SCC of the lip, leaving 68 immunocompetent patients with SCC of the skin. Metastatic SCC developed in 2 patients (5.8% adjusted for losses) within 3 years. The SCCs were small and arose in sun-damaged skin. CONCLUSION Patients with SCC of the skin need a careful follow-up because of the risk of metastasis.