Breast cancer is a common disease in Australia and exerts a sizable burden to individuals, families, and health care resources. Studies that assess healthrelated quality-of-life (HRQoL) are particularly relevant as survivors must learn to live with breast cancer, undergo prolonged treatment, use new pharmacological agents, monitor and adjust to a serious condition. Relatively little published evidence exists on the effects of rehabilitation programs for breast cancer survivors but those published demonstrate positive health benefits that alleviate both physical and psychological problems. This study aimed to partly fill this gap and had the objectives of: a) estimating the effectiveness of two rehabilitation interventions for breast cancer survivors over time compared to a non-intervention comparison group; and b) ascertaining which option was cost-effective when taking a societal perspective. Effectiveness was described in terms of HRQoL and functional status and there was a particular focus on upperbody morbidity since the two interventions primarily addressed this aspect of rehabilitation. The study participants comprised three groups: one group received a physiotherapy home-visits service (DAART), the second attended a gentleexercise group program (STRETCH), while the third represented a nonintervention comparison group for later analyses only. Data collection was primarily by way of postal questionnaires while medical and cost data abstraction was also necessary. Reliable and validated instruments were used to collect HRQoL and utility data. The Functional Assessment of Cancer Therapy - Breast Cancer plus the Arm Morbidity module (FACT-B+4), Disabilities of the Arm, Shoulder and Hand (DASH), and the Subjective Health Estimation (SHE) instruments were chosen for their high psychometric performance with various populations, their brevity, quick administration and relevance to a breast cancer sample. Missing data was a small concern overall, however, baseline differences were present and mixed across the three participant groups indicating selection bias was present. DAART showed poorer demographic indicators of socioeconomic status and were older, STRETCH participants had poorer disease and treatment profile, while the non-intervention women had poorer general health characteristics. Based on bivariate analyses, age, presence of comorbidities, chemotherapy, high blood pressure, work status (unpaid/paid), hormone therapy were determined to be factors requiring control for in the multivariate analyses. Benefits were found for multiple dimensions of HRQoL for the DAART intervention. On average, HRQoL levels were fairly high across the three alternative participant groups and no significant group differences were found. However, approximately one-third of the women experienced declining HRQoL between 6- to 12-months and their scores were significantly poorer than other participants. STRETCH incurred higher overall costs per participant (on average) than DAART and the non-intervention groups. This was driven by higher leisure time forgone, travel and higher community costs. DAART experienced the highest program costs (or health system costs). Therefore, by taking a societal perspective, and incorporating the estimated value of more intangible or indirect costs (e.g., volunteers, travel costs etc.) the STRETCH program was more costly. The greatest influence on higher costs incurred by the STRETCH participants was the average out-of-pocket expenses for health care services purchased during the previous 12 months for breast cancer-related problems. Although an exploratory finding, the DAART group emerged as the cost-effective option, that is, the incremental cost per QALY gained was $1,344 compared to STRETCH $14,478. The key drivers in the cost-effectiveness modelling were utility values and health service expenditure. When uncertainty was quantified by way of Monte Carlo modelling, DAART remained the cost-effective choice. This project has highlighted that while many women seem to breeze through their breast cancer diagnosis and treatment, there are a substantial number of women who do not. Therefore, it is quite mistaken to generalise the favourable levels of HRQoL and expect that all women will get back to 'normal'. Given that HRQoL is a very complex concept, it was important to use validated tools that had undergone extensive testing with sound psychometric properties. Health care activities observed in their natural 'real world' setting are preferable to minimise biases that may cause more favourable results than truly occur and allow a better assessment on the impact of the service. The project findings have been interpreted while respecting a number of limitations. These have included potential selection and response bias, missing data, and small numbers of intervention women and defined socio-demographic profiles. Taken together, these are likely to overestimate the true outcomes. Arguably, selection bias and the timing of the interventions are likely to be the strongest factors affecting the generalisability of these findings. Given the caveats of this research, the following recommendations were made: 1. Greater awareness and/or screening of adjustment problems among survivors needs to be considered during recovery from breast cancer surgery. 2. Early physiotherapy should be given to all breast cancer survivors after surgery due to the potential functional, physical and overall HRQoL benefits that may arise. 3. Professionally-led group exercise therapy with psychosocial care appears to have a neutral effect on upper-body recovery and improving HRQoL. However, it provides advantages for attendees in the form of peersupport, education, a holistic focus and the potential for addressing previously unrecognised psychological problems in a caring and acceptable environment. This program, with large community resources (provided voluntarily), represents a very low-cost outlay for health services and should be given support and consideration during follow-up care after breast surgery. 4. From a societal perspective, a home-visiting physiotherapy service represents a cost-effective means to provide rehabilitative care for breast cancer patients and represents an excellent public health investment. Several topics for further research are likely to be important in the future including, among others, other modes and settings of rehabilitation service delivery, barriers to psychosocial care and the indirect financial and work consequences of having breast cancer.
Introduction Routine collection of patient-reported outcome measures (PROMs) has the potential to inform and improve cancer care. It is now feasible for patients to complete PROMs electronically (ePROMs) providing information about their current levels of symptoms, side effects of treatment and other concerns. PROM scores can be tracked over time allowing more timely identification of problems and more appropriate intervention. Studies have reported clear benefits in patient–clinician communication when PROMs are used and trials in the USA and France found patients randomised to complete regular ePROMs reported better health-related quality of life, had fewer unplanned hospital visits and, importantly, significantly better survival than those randomised to usual care. However, information about the effects on health outcomes and, particularly, the cost-effectiveness of incorporating this information into practice is limited. Methods and analysis PROMISE (Patient Reported Outcome Measures in cancer care: a hybrid effectiveness-Implementation trial to optimise Symptom control and health service Experience) is a multicentre, randomised hybrid effectiveness/implementation trial to evaluate the clinical and cost-effectiveness of using ePROMs in routine cancer care to improve patient outcomes. Participants (target sample=572; randomised 1:1 to intervention and control) are adults aged 18 years or older diagnosed with a solid cancer and starting treatment at one of the four study hospitals. The primary outcomes are unplanned hospital presentations and physical/functional well-being at 6 months. We hypothesise that, compared with usual care, patients randomised to use an ePROM tool will have fewer unplanned hospital presentations, report better health-related quality of life and greater satisfaction with their care and that the ePROM tool will be cost-effective. We will also assess implementation and process outcomes consistent with the RE-AIM (Reach Effectiveness Adoption Implementation Maintenance) Framework. Ethics and dissemination This trial has been approved by the Metro South Human Research Ethics Committee (HREC/2020/QMS/67441). Participants provide written informed consent, including consent for record linkage, prior to completing the baseline questionnaire. Study results will be disseminated via peer-reviewed journals and presentations at scientific conferences and clinical meetings. Trial registration number ACTRN12620001290987.
Historically believed to harbor unrecognized diversity, the taxonomy of the declining genus Macrochelys (alligator snapping turtles) is debated. The original species, M. temminckii, was recently split into M. temminckii, M. apalachicolae, and M. suwanniensis. However, the status of M. apalachicolae is contested. In this study, we generated thousands of genome-wide loci to quantify population structure and genetic differentiation across the range of Macrochelys spp. Our data indicate that M. apalachicolae is genetically distinct, with little gene flow between M. apalachicolae and other species, thus adding evidence that M. apalachicolae may be a distinct species. We also find genetic variation partitioned among river drainages, with very high intra- and interspecific genetic divergence among river drainages. We suggest that translocations and re-introductions only move turtles in this genus within their natal river drainages to preserve existing patterns of genetic diversity.
Abstract Objective To review patient satisfaction with the change in practice towards telephone consultations during and after the coronavirus disease 2019 pandemic for head and neck cancer follow up. Method A retrospective analysis was conducted of head and neck cancer telephone appointments during a six-month period in a tertiary referral centre. Results Patients found the telephone consultations beneficial (98 per cent), with 30 per cent stating they were relieved to not have to attend hospital. Patients who travelled further, those with lower stage disease and patients with a greater interval from initial treatment were most satisfied with the telephone consultations. Sixty-eight per cent of patients stated they would be happy to have telephone consultations as part of their regular follow up after the pandemic. Conclusion Patients found the telephone consultations beneficial and 30 per cent considered them preferable to face-to-face appointments. This study demonstrates that telephone consultations can be used as an adjunct to face-to-face appointments in an effort to reduce hospital attendances whilst maintaining close follow up.
Abstract Background Research suggests that a high proportion of melanoma in situ (MIS) may be overdiagnosed, potentially contributing to overtreatment, patient harm and inflated costs for individuals and healthcare systems. However, Australia-wide estimates of the magnitude of melanoma overdiagnosis are potentially outdated and there has been no estimation of the cost to the healthcare system. Objectives To estimate the magnitude and cost of overdiagnosed MIS and thin invasive melanomas in Australia. Methods Using two different methods to calculate lifetime risk, we used routinely collected national-level data to estimate overdiagnosed MIS and thin invasive melanomas (stage IA) in Australia in 2017 and 2021, separately for men and women. We multiplied the number of overdiagnosed melanomas by the estimated annual cost of a MIS or thin invasive melanoma, to quantify the financial burden of melanoma overdiagnosis to the Australian healthcare system in the year following diagnosis. Results We estimated that 67–70% of MIS were overdiagnosed in 2017, rising to 71–76% in 2021, contributing to between 19 829 [95% confidence interval (CI) 19 553–20 105] and 20 811 (95% CI 20 528–21 094) cases of overdiagnosed MIS. In 2021, the estimated costs in Australia ranged between $17.7 million Australian dollars (AUD; 95% CI 17.4–17.9 million) and AUD$18.6 million (95% CI 18.3–18.8 million). We estimated that 22–29% of thin invasive melanomas were overdiagnosed in 2017, rising to 28–34% in 2021, contributing to between 2831 (95% CI 2726–2935) and 3168 (95% CI 3058–3279) overdiagnosed thin invasive melanomas. In 2021, the estimated costs from thin invasive melanoma overdiagnoses ranged between AUD$2.5 million (95% CI 2.4–2.6 million) and AUD$2.8 million (95% CI 2.7–2.9 million). Conclusions Melanoma overdiagnosis is a growing clinical and public health problem in Australia, producing significant economic costs in the year following overdiagnosis. Limiting melanoma overdiagnosis may prevent unnecessary healthcare resource use and improve financial sustainability within the Australian healthcare system.
Abstract Whether or where to draw subspecies' taxonomic boundaries is much more than an esoteric argument. Subspecific taxonomies and associated geographic ranges have important conservation and management implications because the Endangered Species Act (ESA) protects distinct populations segments below the species level. Genomic data can help resolve taxonomic disputes and assist with conservation policy; however, because subspecific lineages often exhibit gene flow, genomic lineages for subspecific taxa are rarely distinct. We used genomic data from the eastern pinesnake ( Pituophis melanoleucus ) to determine the geographic range of the morphologically variable Florida pinesnake ( P. m. mugitus ), which is petitioned for listing under the ESA. The overall genomic pattern of the eastern pinesnake is one of admixture, and there are gradual differences over the wide range of the species. But there still are discernable areas of genetic differentiation that correspond to the morphologically defined Florida pinesnake, and other subspecies. This pattern of admixture should be expected for subspecies. We propose that boundaries for the Florida pinesnake should maximize the species redundancy, resilience, and representation based on genomic data. We also propose best practices for managers and policymakers interpreting genomic data of subspecies, given that the genomic cutoffs will rarely be truly distinct.
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