Dr Andrew Coleman
Head and neck cancers position statement
Exercise oncology in cancer care
Consumer perspective: Melanoma treatment
A farewell from Mirela
Oral cancer detection
29 Jan 2019
2 minute read
Dr Andrew Coleman
Head and neck cancers position statement
It’s interesting to consider that, in the history of head and neck cancers treatment, Melbourne and Victoria can take particular pride in being innovative forces of improvement for patients. But it isn’t all history—the recent position statement by the Head and Neck Cancers 2018 Summit working party provides excellent, evidence-based and state-wide consensus on what the focus will be for continuing to improve care.
If I can refer us back to the Victorian cancer plan 2016-2020, the statement 'effort should be put into doing consistently what we already know works well’1 is one that is relevant to treating all tumour types—but particularly to head and neck cancers care when viewed through the lens of Victorian Tumour Summits’ work to reduce variations. The working party has considered peer-reviewed local and international research that demonstrates the biggest gains in head and neck cancer outcomes are made by providing correct care—in other words, doing consistently what we already know works well.
The working party position statement is currently with the Department of Health and Human Services. The statement centres optimal care for head and neck cancer patients around the utilisation of multidisciplinary meeting (MDM) review. For optimal care it is recommended that all patients treated with curative intent be prospectively reviewed at an MDM, and that these MDMs should have core membership as per the head and neck cancers optimal care pathway.
A second but no less important consideration is the volume of surgery/radiotherapy of the treating centre. Evidence informs us that patients suspected of having a head and neck cancer need to be managed at a centre that can deliver high quality care. The summit working party has agreed it is not appropriate to treat at centres with less than ten patients a year and that smaller centres should develop networks with larger centres. The party also agrees that it is MDMs with core membership that are best placed to determine and document the treatment plan and most appropriate treating centre for patients treated with curative intent.
Amidst all this ongoing work it is important to pause and take the opportunity that Victorian Tumour Summits affords us to acknowledge each other as state-wide colleagues, and to recognise all of our excellent efforts. Individual Integrated Cancer Services have continued to locally investigate and action areas for improvement. There is now a summit video informing patients and primary health professionals, as well as clinicians, on the prioritised variations for head and neck cancers care in Victoria. Last but not least, well done to the members of the head and neck cancers summit working party, who have continued their labours since the summit in 2018 and ensured a state-wide consensus on the future direction of improving head and neck cancers care.
See here for more information on the Head and Neck Cancers 2018 Summit.
1. Page 38, Victorian cancer plan 2016-2020
27 Feb 2020
2 minute read
Consumer perspective: Melanoma treatment
I came out of radiotherapy in October 2011, and I then had a lump feeling in my stomach. The radiologist wasn't really sure what it was, so off I went for another pathology and PET scan; four tumours were found, which of course it’s metastatic melanoma, because they've moved from the primary. That’s when melanoma is deemed to be stage four; terminal. When [there is distant spread], whilst surgery will work it won't stop it forever because sooner or later it will turn up in a part of your body where you simply can't have the surgery; brain, heart, liver, those sorts of areas.
My clinical trials have become everything to me. My oncologist introduced me to a [clinical] trial for a BRAF inhibitor and a MEK inhibitor, which are two genetic-based drugs that turn off the [production of] these proteins. The melanoma requires [the proteins] to eat and grow. You go into what they call partial remission.
The melanoma cell eventually works out a way to get around that and it re-occurs, but it buys some time. This was another positive for me. It gave me an opportunity to help my kids get through perhaps their VCE if I lasted that long—maybe even their degrees—and it enabled that stability. That was five years ago and I'm still here. The inhibitor drugs that I've been on have been remarkable.
Particularly with melanoma, the last six or eight years have been remarkable. When I lost my neighbour [to melanoma], he virtually had nothing to go on and he passed away in 2007, so it's not that long ago. [At the time of my diagnosis in 2010], really the only things of any substance were the BRAF and MEK inhibitors.
The immunotherapy approach has been even more revolutionary, actually now teaching our immune system to understand what a melanoma cell is so it can attack it. Prior to this drug, our immune system does not know how to identify a melanoma cell, therefore those cells take over and they end up in places where they shouldn't be and they kill you; harsh but fair. The ridiculous thing about it, too, is that I haven't even used those immunotherapy drugs yet, because my BRAF and MEK inhibitors are still working for me. It buys people [up to] maybe three years as a rule. And then there's this really odd group that I'm in five years later, and it's still hanging in there.
The immunotherapy approach has revolutionised [melanoma treatment] to the point where there are some people claiming that they are now cured. It's way too early [to tell]. But the success of these [immunotherapy] trials have been, without a shadow of a doubt, the greatest revolution in cancer research in this country for a long, long time. There are people that have worked in cancer research for 30-plus years and they've seen nothing like the revolution and the improvements of these drug trials in melanoma.
This article is based on Graeme Down's interview transcript for the A Common Path melanoma video, and has been edited for clarity.
29 Jan 2020
4 minute read
Prof Michael McCullough
Oral cancer: Risk factors and what to look for
Oral cancer, commonly known as mouth cancer, is defined as cancer of the lips, oral cavity and salivary glands. Despite advances in treatment, the five-year survival rate still sits around 50-60%. This is due to the fact that oral cancer is commonly diagnosed at a late stage when it is very large and spread into adjacent tissue and local lymph nodes. Most early-stage oral cancer is usually painless, presenting as innocuous lesions that are difficult to recognise during limited examination.
Further, it is not possible to predict if and when there will be malignant change to pre-existing oral lesions. These lesions are relatively common. They occur in around two percent of the population, often appear as flat white areas in the mouth and are termed leukoplakia. Modifiable risk factors play a major causative role in oral cancer pathogenesis. The presence of dysplasia, observed histopathologically in biopsy tissue, remains the best predictor for developing oral cancer. However, the grade of dysplasia does not always correlate with the potential for malignant transformation.
The greatest risk factor for oral cancer continues to be tobacco use with long-term use resulting in about a four-fold increase in risk. Regular consumption of alcohol greater than two standard drinks per day also strongly increases risk by about three-fold. The combination of these two risk factors is greater than either one in isolation. Long-term heavy smoking in combination with alcohol consumption is related to a fifteen-fold increased risk for the development of oral cancer compared to never-smokers and non-drinkers.
Other risk factors for oral cancer include regular use of betel nut, paan, snuff and smokeless tobacco. Prolonged exposure to the sun without proper protection is a significant risk factor for lip cancer. Viruses, in particular the human papillomavirus (HPV) subtypes 16 and 18, have been strongly linked to oropharyngeal cancer; with an increase in the occurrence of these cancers in the last ten years.
However, HPV is involved in only around two percent of oral cancers. Having a genetic predisposition to oral cancer has been postulated to play a role in increased susceptibility. However, no specific genetic changes have been clearly established. In many instances, the risk factors for oral cancer are modifiable. Counselling and education on reducing modifiable risk factors should be provided by health care professionals.
Signs and symptoms
Oral cancer can present in a variety of ways and in any area of the oral cavity. The most obvious clinical presentations of oral cancer are a non-healing ulcer or an exophytic, indurated swelling with or without fixation as well as palpable neck lymph nodes. The most common sites for oral cancer are on the lateral margins of the tongue, the buccal mucosa and the floor of the mouth. Less obvious clinical presentations include white, red or mixed white and red patches that cannot be removed during clinical examination. In the early stages most presentations of oral cancer are painless. In the later stages patients have pain, numbness or altered sensation, as well as difficulty swallowing, chewing or moving the tongue. Patients with oropharyngeal cancers often complain of a persistent sore throat or changes in their voice.
Recently, several adjunctive screening tools have become available, purportedly capable of assisting with examination and detection of oral cancers. Currently, none have demonstrated superior efficacy over thorough oral examination with good lighting to visually examine the entire oral mucosa. Any lesion that has persisted for more than two weeks without a definite cause should be referred for immediately biopsy. It should be recognised that the major cause of oral mucosal changes is trauma, and such things as sharp cusps of teeth, broken fillings, and ill-fitting dentures often cause persistent oral mucosal changes. These causes need treatment and should be reassessed for healing two weeks later. Failure to improve within two weeks should prompt the clinician to refer the patient for further management.
Patients suspected of having oral cancer should be referred to an oral medicine specialist or oral and maxillofacial surgeon for further assessment. Assessment would include a comprehensive oral examination including extra-oral examination and palpation of the lymph nodes in the head and neck region. A full intra-oral examination using white dental light would be conducted. The need for adjunctive tests, including blood tests, selective imaging, diagnostic aids, cytology and histopathological assessment, will be determined at the clinician’s discretion at the time of examination. For definitive diagnosis, histopathological assessment of biopsy material is required.
Definitive diagnosis of oral cancer necessitates referral to a tertiary hospital for multidisciplinary treatment planning and management. In the first instance, the patient would undergo extensive imaging including CT, MRI and, often, ultrasound examination; so that accurate staging can occur to guide treatment. Multidisciplinary management usually consists of multiple treatment modalities including a combination of surgery, radiotherapy and/or chemotherapy. The team involved in managing a patient with oral cancer usually consists of oral and maxillofacial, plastic, and head and neck surgeons; radiation oncologists; speech pathologists; radiologists; dietitians and other dental specialists. The best management outcome for the patient is surgical eradication of the cancer at an early stage.
Prevention and early detection
Patients at risk of developing oral cancer should be counselled by health care professionals to reduce risk factors, particularly smoking and drinking alcohol, to decrease their chance of developing oral cancer. Those with oral mucosal changes that have the potential for malignant change should be reviewed regularly by either an oral medicine specialist or an oral and maxillofacial surgeon. Self-monitoring for changes in appearance and consistency of a lesion between review appointments should also be encouraged, so that patients can re-present earlier if they are concerned.
Exercise oncology in cancer care
Exercise is a safe and effective inclusion in cancer treatment, resulting in improved physical function and psychological outcomes for patients 1. The evidence demonstrates that cancer patients who exercise at the recommended level experience a lower number and severity of side effects, improved quality of life and have a lower recurrence and mortality rate when compared with their less physically active counterparts 1–3. In May 2018, the Clinical Oncology Society of Australia (COSA) released a position statement, ‘Exercise in Cancer Care’, calling for the inclusion of exercise in standard cancer care.
Research also illustrates that medical/clinical recommendation of exercise does not result in patients engaging in exercise behaviours sufficient to realise health benefits. Currently in Australia, approximately 60–70% of people with cancer do not meet aerobic exercise guidelines and approximately 80–90% do not meet resistance exercise guidelines 1, 4. While many people with cancer have indicated a desire to participate in appropriately designed and supervised exercise programs, only a minority are engaging in sufficient levels of exercise 4–6.
(Clinical Oncology Society of Australia, COSA Position Statement on Exercise in Cancer Care 2018: Level 14, 477 Pitt Street. Sydney NSW 2000)
What is moderate-intensity exercise?
Intensity refers the magnitude of the effort required to perform an activity or exercise. The intensity of different forms of physical activity varies between individuals and depends on a person’s previous exercise experience and relative level of fitness 7. Moderate-intensity exercise requires patients to work at a level of exertion equivalent to 40–59% of heart rate reserve; that is, exertion perceived as ‘somewhat hard’. Examples are brisk walking, cycling and/or swimming at a somewhat hard pace 1.
Implementing exercise as part of standard care at the Olivia Newton-John
In 2019, the ‘Wellness Gym’ was launched onsite at the Olivia Newton John (ONJ) Centre along with an outpatient exercise oncology service for patients undergoing cancer treatment at the ONJ. The implementation of an outpatient exercise oncology service aimed to provide appropriately designed exercise programs delivered by oncology-specialised exercise physiologists, addressing the gap in service provision. This has been developed to align patient care at the ONJ with COSA recommendations and ensure that ONJ patients are receiving evidence-based best practice.
At the ONJ, we have designed and implemented a dual pathway exercise oncology service. This service design allows patients to select between centre-based supervised exercise or home-based phone coaching. In the first six months of service there was an even demand for both supervised exercise and home-based phone coaching. All participants receive a 1:1 initial assessment with tailored education and exercise prescription.
In the first six months of operation, 259 referrals were received for exercise physiology, with 73% of referrals being initiated by nursing staff. Of 231 eligible referrals, there was an 87% consent rate:
Over an 8–10 week intervention, participants demonstrated improvement on both functional and Self-Reported Quality of Life measures:
Participant feedback has been overwhelmingly positive, with common themes that are in line with the benefits of exercise reported in research literature. Patients reported:
- a sense of control
- increased confidence
- a sense of community and support
- improved energy
This project has been successful in demonstrating the feasibility and the benefit of an outpatient exercise service for oncology patients undergoing cancer treatment and that exercise as part of cancer treatment has been widely accepted by both patients and health professionals within the ONJ. At this point in time the exercise oncology service continues to be philanthropically funded and is yet to have hospital operational funding.
Kirsty McRae is an exercise physiologist at ONJ. For more information, contact <ONJExercise@austin.org.au>
1. Clinical Oncology Society of Australia, COSA Position Statement on Exercise in Cancer Care 2018: Level 14, 477 Pitt Street. Sydney NSW 2000
2. Hayes, S.C., et al., Australian Association for Exercise and Sport Science position stand: optimising cancer outcomes through exercise. Journal of Science & Medicine in Sport, 2009. 12(4): p. 428-34
3. Rock, C.L., et al., Nutrition and Physical Activity guidelines for cancers survivors. CA: A Cancer Journal for Clinicians, 2012. 62(4):p 243-74
4. Eakin, E.G., et al., Health behaviors of cancer survivors: data from an Australian population-based survey. Cancer Causes Control, 2007. 18(8): p. 881-94
5. Short, C.E., et al., Main outcomes of the Move More for LifeTrial: a randomised controlled trial examining the effects of tailored-print and targeted-print materials for promoting physical activity among post-treatment breast cancer survivors. Psychooncology, 2015. 24 (7): p. 771-8.
6. Galvao, D.A., et al., Compliance to exercise-oncology guidelines in prostate cancer survivors and associations with psychological distress, unmet supportive care needs, and quality of life. Psychooncology, 2015.
7. World Health Organization. (2010). Global Recommendations on Physical Activity for Health. Geneva , Switzerland.
13 Jan 2019
1 minute read
A farewell from Mirela
After five years of managing VTS, I am moving on to the next chapter in my career with Uniting Vic/Tas. I owe thanks and gratitude to my team and amazing people who have been part of VTS successfully engaging Victorian cancer clinicians in reducing unwarranted variation in care. But before I thank you all, I would like to share a few insights which may be useful to those who are working on health system reform:
- Identifying variations in care is not that difficult if you have access to quality population data, appropriate data analytics expertise and clinical experts to guide data analyses. Having a combination of the three is particularly important and missing one may undermine the quality of the outcome. In all seven tumour streams we activated, clinical working groups collaborated with data analysts on understanding the benefits and limitations of using population data for prioritising unwarranted variations for state-wide action.
- Victorian Tumour Summits are clinician-led forums to identify unwarranted variations in tumour-based clinical practice and cancer outcomes that could be addressed through state-wide action. Having this clearly-articulated purpose for clinical engagement kept the focus on the process of engagement and away from temptations to control which specific variations should be prioritised for action. Through this process the members of clinical working parties embraced the responsibility of engaging a broader group of clinical stakeholders at summits and beyond through VTS communications.
- Designing a communication strategy to inspire action beyond each summit supports ongoing clinical and stakeholder engagement in cancer service reform. Several clinical leaders continued their involvement in local and state-wide initiatives. Many clinicians initiated their own audits and improvement projects to investigate whether variations observed in the population data indicated unwarranted variation in their local care. For examples of ongoing work visit the VTS webpages.
My sincere thanks go to exceptional clinical leaders, consumers and colleagues who generously contributed their cognitive surplus to advancing the Victorian cancer reform agenda: Ahmad Aly, James Armstrong, David Ball, Lisa Briggs, Ken Bottrell, Damien Bolton, Paul Cashin, Geoff Chong, Christopher Christophi, Andrew Coleman, Barry Curran, Megan Dendle, David Deutscher, Spiri Geletakis, Brian Hodgkins, Jeremy Millar, Rebecca Miller, Paul Mitchell, Charles Pilgrim, Amy Sercombe, Katherine Simons, Veronica Strachan, Ella Stuart, Jeff Szer, Luc te Marvelde, Luellen Thek, Robert Thomas, Lesley Thornton, Stephen Tudge, Kathryn Whitfield, Gavin Wright, and many others.
29 January 2020
2 minute read
Consumer perspective: palliative care for lung cancer
Cassandra Morris was an amazing mother of three girls and a beautiful wife—always busy and taking great care of her family. Acute pain in her thoracic spine in May 2017 was the beginning of a devastating diagnostic, then treatment path. It would see us lose her far too soon—12 months to the day of being diagnosed with stage IV lung cancer on 19th June 2007.
Cassywas diagnosed with EGFR lung cancer. The targeted therapies available provided some hope of stabilising the disease for a reasonable period of time. After managing the disease for around six months with Iressa, things took a catastrophic turn. Severe headaches and dizziness, just before Christmas and early in the new year, hospitalised Cassy. CT scans gave an initial all clear. However, a follow up MRI confirmed the worst brain metastasis of leptomeningeal disease.
After whole-brain radiation therapy and switching targeted therapies, then switching again to combined chemotherapy and immunotherapy, Cassy was suffering immensely. Pain was becoming increasingly difficult to manage. It was discussed that palliative care may provide better options. The bone metastatic disease was severe.
At this point, Cassy was admitted to palliative care. The focus was to get her on methadone as the primary pain drug. After five days, she was released in good spirits. However, soon after, she was extremely sick and was readmitted, literally fighting for her life. She was in a coma.
The palliative care team suggested she might not wake up. They asked us what we wanted to do. I said, ‘We need to fight for her. She would want more time with our girls.’ After a week she awakened. We then learned the brain cancer had returned and she was running out of time. They gave her about a month.
The palliative care team were so supportive. The hospice was relaxed and family friendly. We stayed with Cassy often and staff even arranged for extra bedding to facilitate this. We would watch movies and family and extended family were welcome. We celebrated our daughter Kiara’s seventh birthday there. The compassion and care afforded to Cassy and us all was beautiful.
It really takes very special people to do this day in and day out. It must take a toll on people over time. The palliative care doctor also put us in touch with lung oncologists at Peter Mac so we could discuss accessing trial drugs. This request was accepted, however, sadly it was just too late.
In our last days and hours with Cassy, palliative care took such good care of her (and us). Cassy slipped back into a coma state for the last week of her life. I wanted to try and wake her up. I just knew that it was what she would want, but the doctors insisted they would not give her more cortisone and that the time had come. I was and remain conflicted about this, as I knew my wife. It was in contradiction of her spirit and her will to live. She would have wanted to be present, no matter how painful. I just wanted her to see her family and have an opportunity to speak or interact with us all one more time. To see our girls, and for them to say goodbye.
Once she slipped away, we were given so much time with her. This was so important; we had just lost the centre of our world. For my children to be with her and to hold her, for me and my family. This I am very grateful for, and for the amazing support and service afforded to us during the most difficult time.