Author

Article

Author

Article

Matthew Browne
CEO
Melanoma Institute Australia

Event management during COVID-19
04/06/2020


Kirsty McRae
Exercise physiologist

Exercise oncology in cancer care
27/02/2020


Dr Andrew Coleman

Head and neck cancers position statement
29/01/2020


Mirela Matthews

A farewell from Mirela
13/01/2020


Cancer Council Victoria

Optimal care pathways refresh project
06/07/2020


Prof Jeremy Millar
Chair
Cancer Council Victoria
Effective communication for telehealth
04/06/2020

Graeme Down

Consumer perspective: Melanoma treatment
27/02/2020

Consumer perspective: Melanoma experience
30/04/2020


Kane Morris

Consumer perspective: palliative care for lung cancer
29/01/2020


Paula Howell
Project Officer
NEMICS

Colorectal cancer shared care pilot update
04/06/2020


North Western Melbourne Primary Health Network

Improving cancer care within primary care
30/04/2020


Prof Michael McCullough

Oral cancer detection
29/01/2020

 
The Cancer and COVID-19 in Victoria series is hosted by the Victorian COVID-19 Cancer Network (VCCN), a partnership of the VCCC alliance and the MPCCC

Health care professionals are invited to subscribe to the VCCN:
https://www.viccompcancerctr.org.au/victorian-covid-19-cancer-network/

Cancer and COVID-19 in Victoria: Communication in a time of crisis
04/08/2020

Cancer and COVID-19 in Victoria: unpacking the complexities of
providing palliative care services during a pandemic

12/10/2020
 

   


Victorian Tumour Summits

David Deutscher on the past and future of VTS
11/09/2020

 

4 June 2020
3 minute read

Matthew Browne

Event management during COVID-19

What happened before the introduction of COVID-19 event restrictions in 2020?

Melanoma March had 24 marches scheduled for this year. It’s a very important month for Melanoma Institute Australia in terms of awareness, fundraising and ability for community to come together. The marches are held on Sundays throughout month. We held five marches on Sunday 8th March. COVID-19 had just started to be talked about in a serious way. But there was no restriction on events at that time.

We chose to be stricter than the restrictions. It became very apparent all events [for the rest of the month] would need to be cancelled. This included our signature event at Manly in NSW and events in Brisbane, Perth and Adelaide. It was a very difficult decision to make. A lot of hours had been put in by people and it had to be cancelled overnight. But we received positive feedback at the time that it was clear and decisive and the right thing to do.

How did you get community feedback on what to decide?

It was important but not easy to get at the time, as things were happening so fast. Our events are run by volunteer groups, normally one or two people and a bunch of their friends and family that are really keen to put on one of our events. Melanoma Institute Australia then provides the infrastructure and brings it all together nationally. We contacted the volunteer event committees and made a decision. We didn’t poll the broader community due to needing to do it so quickly, so we made [the decision] on their behalf. 

What happened after cancelling?

Once we made the decision to cancel the physical event, we realised from a fundraising and awareness point of view that it was over. The decision around the virtual march was more intuitive, in that another and no less important element of our marches is community gathering and the ability for the community to feel supported by each other. The vast majority of people at marches are affected by melanoma, so it provides optimism and support for those that come. We felt we’d lose a big chunk of this. So, we felt quickly that we had to have a virtual event. But [when] we announced it, we didn’t know what it would be. [We just knew it was about] giving those that had worked so hard on their cancelled events an opportunity for their communites to come together in a virtual way.

How did you work through virtual event options?

It was based on our capacity. What we could do in such a short timeframe. We needed to be able to do something that allowed for the amount of restrictions occuring. We didn’t want to do something that required meet-ups and walking around the block. So we based it on family interactions and rememberence of those that we’ve lost to melanoma and to those that have it now. We knew that regardless of restrictions this could be achieved, so that’s why it was brought to something relatively simple but that people could be engaged with. Because people had their focus on COVID-19.

It was also about honouring the quality of the physical eventwe wanted to meet a relatively high standard. We asked our key collaborators for a one-minute video and we got a lot—so much was going on but people took the little bit of time, which was fantastic.

How did you implement moving from a physical to virtual event?

We told our community by social media and our regional media outlets re-did the releases and promoted the virtual march—they were fantastic. We didn’t push the fundraising, although people did still donate. It was asking people to come together to hear stories and share their own. 

What are the lessons learned for future virtual events?

I don’t think it will replace the physical event in the future—I’d like to think we will still be able to do that. The support and comraderie of having a group of a thousand people is hard to replace online. But we learned that rural and remote areas can be included in our marches, and we can provide those communities with a virtual event. And also for people with disabilities who may not be able to physically attend. So I see us having a combination of our physical and virtual event.  It does give that additional access that we hadn’t necessarily thought of before [the restrictions]. 

Melanoma Institute Australia CEO Matthew Browne was interviewed by VTS. This article is based on the trascript and has been edited for clarity. Melanoma March Virtual can be viewed here.

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6 Jul 2020
2 minute read

Cancer Council Victoria

Optimal care pathways refresh project

The original optimal care pathways (with the exception of the Aboriginal and Torres Strait Islander optimal care pathway) were first developed in 2014–2016. Since their development, advances in cancer care continue to emerge. It is therefore timely to review and update the OCPs, ensuring they are relevant to current practice. The clinical expert working group for each OCP has updated the cancer-specific information based on recent guidelines, known evidence and experience and expertise of the clinical expert working group.

We value your input to help us to improve the OCPs and quick reference guides and invite you to provide feedback on the updated OCPs. The OCPs which we are currently seeking feedback on are:

  • breast cancer
  • endometrial cancer 
  • head and neck cancer 
  • Hodgkin and diffuse large B-cell lymphomas 
  • ovarian cancer.

The opportunity to provide feedback will close on Tuesday 28 July 2020 [update 31/07/2020: now extended to Wednesday 5 August]. If you would like to review and provide feedback on an OCP for one or several of the cancer types listed above and below please email <Julia.Brancato@cancervic.org.au> and Julia will send you the draft.  

The next group of OCPs which we will be seeking feedback on at the end of July 2020 include:

  • acute myeloid leukaemia
  • basal cell carcinoma or squamous cell carcinoma
  • melanoma
  • pancreatic cancer 
  • prostate cancer. 

The refreshed optimal care pathways are expected to be published at the end of 2020 and early 2021. This work is essential to ensuring people affected by cancer receive the best care available. This project is funded by the Victorian Department of Health and Human Services, with project oversight by Cancer Council Victoria.

Background

The optimal care pathways map seven key steps in cancer care. They provide a national standard for the high-quality cancer care that all Australians should expect. 

The principles underpinning the optimal care pathways always put the patient at the centre of care throughout their experience and prompt the healthcare system to deliver coordinated care.

There are three resources for each pathway: the optimal care pathway (comprehensive version), the quick reference guide for health professionals and the what to expect guide for patients, carers and families. There is a specific optimal care pathway for Aboriginal and Torres Strait Islander people, and the what to expect guides for consumers are available in plain English and seven languages.

The most recent optimal care pathways developed are for women with cervical cancer, for people with sarcoma (bone and soft tissue) and for people with cancer of unknown primary. 

The optimal care pathways are endorsed by Cancer Australia, the National Cancer Expert Reference Group (a committee that reports to the Australian Health Ministers Advisory Committee) and all states and territories. The optimal care pathways have Australia-wide acceptance and government support.

Visit the Cancer Council website  to view the optimal care pathways (comprehensive version) and quick reference guides.
 
Visit the Cancer Council’s cancer pathways website to view the what to expect guides. 

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29 Jan 2020
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

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27 Feb 2020
2 minute read

Graeme Down

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. 

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30 April 2020
2 minute read

Graeme Down

Consumer perspective: Melanoma experience

I'd like to think I’m a positive person, but not blindly so. There are a lot of people who ignore the harsh facts of life at times, because they wanna keep that very positive attitude. Somewhere there's a mix. You've got to confront the very harsh facts of life. Being as positive as you can is a step in the right direction, but to be blind to the truth doesn't help you either. I'm comfortable with my fact approach, but as positive as I can be.

Without my wife... I have four children, all of whom at the time were living at home, and without them I would have been completely lost. I used to get up every morning five days a week and enjoy going to work but with the greatest of respect to my professional life, it was secondary to my home life. I had to keep the relationships at home as normal as possible, as ill as I may have been. My eldest two were at uni, the next two were still at school heading towards their VCE, so it was at a very crucial time for all four of them, study-wise. 

It was a tough time for them. My children all had different approaches. A couple of them would ask me more questions than I really knew the answers for. Others would just sit there and take it all in, and sort of go away and absorb it themselves. So it was a different confirmation process between all of them. One of my sons, in particular, was just looking for the silver bullet. Because his view was that it's not fair that I've got a terminal illness. So he just kept asking until we gave him the silver bullet, and it wasn't there to be had. So it was a worthwhile exercise because it confronted me as well as him. We both had to realise that there is no cure, yet. 

I was having real stress. I didn't know it at that time. Every time I had scans coming due again, my headaches would start to rise. And when they were clear, the headaches would go away. So I sort of sat back and thought, ‘Well, there's no second tumour there. So I'm creating a lot of this myself.’ So I went to see a psychologist for help on how I could manage that a little bit better. They gave me a whole bunch of different options about ways I could handle those sorts of things.

As it happens, the thing that worked best for me was the physical work that I could do. Now, the drugs that I'm on, fatigue limits me. But something just as simple as walking my dog every day for an hour was worthwhile. It took me back to when I was a kid. Whenever I had a tough day at uni or at school, or even at work; come home, put the runners on, go for a walk, go for a run, blow the brain out, get rid of the cobwebs. It was a blank time because my dog didn't talk to me much—he just liked to go for a walk. It gave me time to think things through, reject, look forward, look back, process the naughty bits, process the good bits. And I'd come home from a walk around the block much more clearly than I walked away.

One of the attitudes I've had right from the very early days was not to second guess what might or might not be around the corner. That was certainly where my head was early days; worrying about A, B, C happening or not happening. It just seemed to me to get you into dark places and confused places. So I tried to take it one day at a time. If there were good days, there were good days; if there were bad days, there were days that weren't so hot, and that's true of life whether you're unwell or not. So I try to take it one day at a time and approach it as well as I can, but also as practically and honestly as I can and share that with whoever will listen and move on. If that's next week, if it's the week after, we worry about that when that happens, not before.

This article is based on Graeme Down's interview transcript for the A Common Path melanoma video and has been edited for clarity. 

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4 June 2020
2 minute read

Paula Howell

Colorectal cancer shared care pilot update

International randomised control trials comparing oncologist and primary care follow-up of colorectal cancer (CRC) survivors identify no important differences in outcomes. Trials also report that shared care is safe, feasible and acceptable1. Despite this, CRC shared care remains in its infancy in Victoria. 

The Department of Health and Human Services and NEMICS funded a three-year pilot of CRC shared care at Monash Health and Eastern Health. Southern Melbourne Integrated Cancer Service and the PHNs were project partners. The School of General Practice at the University of Melbourne evaluated the pilot. The pilot sought to test the feasibility and acceptability of CRC shared care in Victoria.  It aimed to deliver a recovery-orientated model and to learn how to sustain the new model of care beyond the pilot period.  

Designing the model

Survivors treated with curative intent surgery and chemotherapy for stages I-III CRC were eligible for shared care. Survivors of low rectal cancer were either excluded or entered shared care later. 

Risk stratified follow-up pathways and a shared care plan were based on tools developed for S.C.O.R.E., a concurrent randomised controlled trial of CRC shared care, conducted by the Victorian Comprehensive Cancer Centre. Co-design approaches helped refine the shared care plan, risk stratified pathways and processes. The shared care model included appointment reminders, education about symptoms to report and rapid re-entry to specialist care in the event of suspected recurrence. Specialists retained responsibility for scans and colonoscopies and alternated CEA monitoring, history taking and examination with GPs. An allied health professional coordinator facilitated follow up. The coordinator also completed needs assessments and provided interdisciplinary triage and referrals. 

Findings

Shared care was highly acceptable to survivors, specialists and GPs, although the degree of GP engagement varied.  All specialists consented to participate, as did all GPs except one.  In total, 122 survivors were offered shared care. Of these, 114 (93.4%) accessed shared care and 100 (81.9%) consented to the study.  A competing ctDNA clinical trial impacted recruitment at one health service.

Shared care was feasible and delivered tests in line with surveillance guidelines for the majority of participants. A sample audit of 80 CEA blood tests found a mean and median of 98 and 92 days respectively between tests (target 90-93 days).  Compliance with annual CT scans was strong (mean 364 days, median 362 days).  Compliance with colonoscopy was strong at one health service but often delayed at the other service due to waiting lists. Mechanisms for rapid re-entry to hospital clinics were effective as long as the care coordinator remained involved until (recurrence) treatment planning commenced. 

Despite overall strong compliance with follow-up, some participants delayed attending tests, required repeated reminders or failed to attend appointments. Some disadvantaged, elderly and CALD populations required intensive care coordination support to adhere to follow-up. Variance to planned follow-up was frequent due to abnormalities on imaging and some communication breakdowns with private specialists. Further work is needed to embed a more systematic model of shared care and to improve consistency of communication across specialities.

Clinic attendances were reduced by up to half and the shared care coordinator assisted to reduce unnecessary and duplicated appointments. 

In total, 70 referrals were made to services including:

  • Community rehabilitation services
  • Continence physiotherapy
  • Dietetics
  • Exercise physiologists
  • Non-government organisation cancer support services.  

Shared care for CRC has continued at Monash Health following the pilot.

1. McCabe M, Partridge A, Grunfeld E, Hudson M 2013, ‘Risk-based health care, the cancer survivor, the oncologist, and the primary care physician’, Seminars in Oncology, vol.40, no.6, pp.804-812

This work could not have been completed without the support of SMICS, Monash Health, Eastern Health and Eastern Melbourne Primary Health Network. Special acknowledgements and thanks to Alicia Davies, Prof Jon Emery, Dr Michael Franco, Mr Brian Hodgkins, Mr Jamie Keck, Jasmeen Oberoi, Narelle Quinn, Seleena Sherwell, Mr William Teoh, Yvette Vonier and Dr Rachel Wong.

For more information, contact NEMICS Project Coordinator <Paula.Howell@austin.org.au>

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29 Jan 2020
4 minute read

Prof Michael McCullough

Oral cancer: Risk factors and what to look for

Overview

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.

Risk factors

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.

Assessment

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.

Management

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.

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27 Feb 2020
2 minute read

Kirsty McRae

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.

Recommendations:

(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
  • enjoyment. 

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>


References: 
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.

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13 Jan 2020
1 minute read

Mirela Matthews

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:

  1. 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.
  2. 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.
  3. 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.

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4 June 2020
2 minute read

Jeremy Millar

Effective communication for telehealth

The COVID-19 pandemic led to a rapid uptake of telehealth services, raising critical clinical questions and challenges for health professionals to provide optimal care for cancer patients. We’re hearing mixed reactions—through Cancer Council’s 13 11 20 information and support line—from patients about their experiences using telehealth. While some people welcome it, others have shared anxiety, confusion and dissatisfaction with their telehealth appointments.

Julie, who is living with stage 4 lung cancer, began with face-to-face appointments that went for about an hour. Since COVID-19, she has been shifted to telehealth and most appointments have been less than ten minutes. 'Up until the pandemic was declared my appointments were face-to-face,' Julie said. 'I found the appointments very beneficial as I was able to ask questions. My family also took the opportunity to ask questions of the specialist. All my appointments are now via telehealth with the specialist oncologist…I feel the appointments are very quick, and do not leave enough time to ask questions or process my thoughts.' 

Webinar: enhancing communications skills for telehealth delivery

Cancer Council Victoria in collaboration with the Victorian Comprehensive Cancer Centre and Monash Partners Comprehensive Cancer Consortium recently presented a webinar on enhancing communication skills for telehealth delivery. View the webinar here.

The webinar was moderated by Adjunct Clinical Associate Professor Zee Wan Wong, a medical oncologist at Peninsula Health and featured panellists Kate Barber, a clinical nurse specialist at Cancer Council; Peter Martin, Professor of Communication and End of Life Care at Deakin University and Dr Rob Campbell, a general oncologist at Bendigo Health. 

Practical communication tips shared by the panellists: 

  • The importance of a pause. Clinicians commonly forget to allow for a pause for people to process information during telehealth consultations. Evidence suggests that a pause of 3-5 seconds is needed for people to clarify your comments or questions or allows other people to speak. 
  • Slow down. The pace of a conversation should be slowed down but this is even more relevant with telehealth, particularly when providing information to the patient. Speak slowly and use non-technical language. 
  • Explicitly express empathy. Some non-verbal cues can be lost with telehealth regardless of how good the technology is. Clinicians must make more effort to audibly express empathy when communicating with the patient. 
  • Don’t forget to actively listen. Telehealth technology can make it easier to become distracted meaning you might be thinking of the next question you are going to ask and miss important verbal or non-verbal cues.
  • Ensure the patient understands what was discussed and allow time for questions. Use reflecting or clarifying questions E.g. “Does what we have just spoken about make sense to you?” At the end of the appointment get the patient to summarise what they understand and repeat it back to you E.g. “I want to be sure I explained everything clearly. Can you tell me how you are going to take this medicine?” 
  • Smile. Don’t forget to smile- even if it’s on the phone. Patients can hear the difference and it helps build rapport.

Source: S Sabeson, D Tucker, Doctor patient communication and relationship in telehealth, MJA, 11 May 2020 
https://insightplus.mja.com.au/2020/18/doctor-patient-communication-and-relationship-in-telehealth/ 

Useful resources 

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29 January 2020
2 minute read

Kane Morris

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 andBack to top 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. 

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30 April 2020
1 minute read

North Western Melbourne Primary Health Network

Improving cancer care within primary care

The first regional consultation and implementation forums were held around the state in the second half of 2019. These DHHS-funded initiatives were designed and delivered by all Victorian Primary Health Networks (PHNs) with the aim to discover the enablers and barriers to implementing the optimal cancer care pathways (OCPs) into primary care. The forums were attended by GPs, practice nurses, allied health professionals, ICS staff and other key stakeholders within the OCP cancer network.  

Each event focussed on the role of general practice in the first two steps of the OCPs: ‘prevention and early detection’ and ‘presentation, initial investigations and referral’. Some of the insights that arose from the forums were: 

  • There is a perception that cancer care is outside of the scope of primary care. 
  • Primary care is more likely to encourage screening for cancers that have specific programs that they can refer to, e.g., BreastScreen Australia. 
  • Early detection is limited to primarily GPs, when nurses and allied health professionals could and are willing to be upskilled in this area.
  • The translation of the OCPs into HealthPathways has helped provide GPs with an up to date, dynamic resource that supports referral and management of cancer patients.
  • There is a need to streamline the referral and triage process. 

The forums allowed for robust discussion around how OCPs are implemented into general practice, as well as on the challenges faced individually and collectively by primary healthcare practitioners. The insights collected from the day will help shape PHNs’ recommendations for future action by and involvement of primary care in the cancer continuum. 

The forums were very well received by attendees, with many stating that the most useful aspects of the day were having the time and space to sit and brainstorm with their peers, and hearing about the benefits and challenges that their peers faced on a daily basis. Overall, attendees felt that the events ‘were a great day, well done’ and that ‘I would love to come [to the next one].’

Planning for the next iteration of forums is underway, likely to be held across the state in late 2020. The focus will be on the role of primary care in the management of patients undergoing active cancer treatment, as well as survivorship care. 

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4 Aug 2020
2 minute read

Victorian COVID-19 Cancer Network

Cancer and COVID-19 in Victoria: Communication in a time of crisis

There are challenges to health professionals and organisations achieving effective communication during this time of providing ‘COVID-normal’ health care. Some of these challenges are:

  • Encouraging people to see GPs and present at the ER when necessary
  • Providing safety information to the general public and patients
  • Continuing to raise awareness of health institutions’ core work
  • Using social media effectively
  • Messaging a culturally diverse community and people with disabilities
  • Determining how and where your organisation fits into COVID-19 and letting your stakeholders know. 

There are some core principles of communication during a pandemic that have not changed since print media became widely available. These are:

  • clarity
  • visibility
  • relevance
  • timing

A more recent development in communications is greater use of images and infographics, which are known to be more effective than copy. Images also have the advantage of being cross-cultural and -lingual. 

Role modelling in images is powerful. It’s important for every leadership team to visibly model the the behaviours desired in the broader population. This reinforcement and daily reiteration of the ‘change you want to see’ enables the key messages to become meaningful and practiced.
 
The broader community also plays a role, particularly through the use of social media platforms. There are conversations going on around ‘business as usual’ health support that are unrelated to COVID-19—conversations that need to continue and be amplified by stakeholder organisations. 

For organisations using social media, acknowledge and respond to COVID-19 on your platforms; these are real-time channels and therefore operate hand-in-hand with current events. However, make sure stakeholders also know core work continues, particularly research. Celebrate your champions and your wins, and use humour carefully. Only use COVID-19 hashtags if appropriate. Consider if your language and terminology is appropriate. For example, an error in COVID-19 health messaging was initial use of the term ‘social distancing’, compounded further with the change to ‘physical distancing’. These terms are too similar to be distinguishable.

With the rapid developments in COVID-19 news and fast-changing regulations, it won’t be possible to always get it right. When there is a deficit between the messaging and what people are understanding, communications need to be corrected.  For example, there was recent confusion in Victoria over the initial messaging regarding hospital visitation during and after childbirth. This was fixed through clarification.

If you are an organisation that needs to put into place a communications plan for COVID-19, some tips are:

  • Look at organisations who are doing their communications well
  • Look at previous communications for crisis responses, eg. the 2019-2020 Australian bush fires
  • Identify key messages and how your organisation is responding to COVID-19, but don’t let it dominate from your core work
  • Be a trusted source of information and partner with other organisations. Are there opportunities to increase your reach?
  • Make sure communications staff have a ‘seat at the leadership table’ during strategising and decision making.

This article is based on the VCCC alliance webinar 'Cancer and COVID-19 in Victoria: Communication in a time of crisis'.  It is a summary and interpretation of the content and does not represent the views of the presenters or hosting body.

Health care professionals are invited to subscribe to the VCCN:
 https://www.viccompcancerctr.org.au/victorian-covid-19-cancer-network/

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12 Oct 2020
2 minute read

Victorian COVID-19 Cancer Network

Cancer and COVID-19 in Victoria: unpacking the complexities of providing palliative care services during
a pandemic

World Hospice and Palliative Care Day was held on Saturday 10 October this year. The VCCC alliance held a webinar, ‘Unpacking the Complexities of Providing Palliative Care Services During a Pandemic’, as part of its Cancer and COVID-19 in Victoria online series. 

Palliative care is particularly affected by the pandemic due to the pandemic's impact on the nature of palliative care as a discipline, which centres on physical presence, touch, and face-to-face relationships.

Victoria is seeing firsthand some of these issues. Translating the Chief Health Officer’s directives, which drive policy change at a broader legalistic level, and reconciling the impact these directives have on individuals and their families is challenging and emotional. Three significant directives need alignment in this particular arena; being hospital-, care facility visitors-, and stay-at-home directions. 

Tension arises from the convergence of these directions. In addition, the number of times directions have changed reflects the issue of living and working in what is an evolving space during a pandemic. It also indicates the time it is taking for alignment of directions to occur. 

On top of this, there is the added trauma of death and dying during COVID-19 for palliative patients, their families and carers, which doesn’t exist in non-pandemic times. There are immediate and longer-term effects on surviving relatives that will continue for years and will likely need funding and support. Health professionals now carry the added burden of wondering if they have contributed to some of the trauma of this pandemic through decisions made and the way that care has been provided.  There is still a question of what would be done differently if there is a third wave. 

There is also the impact on health care workers, who normally would not face an infectious risk of this magnitude in their occupation, or a risk of infecting their families. There is currently an ethics consideration that is not normally present in palliative care, where what is good for the individual patient, such as leniency regarding increased visiting time, can now potentially be catastrophic for tens or hundreds of other patients and staff. 

Cancer Council has been collaborating with peak bodies to share challenges. A lot of queries are from the community, who are confused as to how to interpret some of the guidelines around visitors. Strongest feedback is that there is inconsistency in the  interpretation of guidelines. While it’s a positive that the most recent hospital guidelines are addressing some of the challenges of palliative care, people are currently having different and negative experiences, particulary those with the least health literacy.

Cancer Council is receiving approximately 180 calls a day in relation to COVID-19. One example was an end-of-life patient in a 'COVID-free' region, who could not be with their child at the time of death because their infant grandchild was not allowed in the room.  One quote from a member of the public was, ‘Mum was a victim...She won't be counted in the statistics because she didn't have the virus, but she was the victim of what this virus does to people who have terminal illness.’

So, how do health care workers operate sustainability during this time? One suggestion is remembering that the goals are the same during difficult times as in good times; in fact, it is during difficult times that these goals take on greater meaning. Another observation is that colleagues are now taking the time to look out for one another, when traditionally healthcare hasn't always excelled at this. A learning during this time is we only provide services as good as the support that we provide for one another as well.

This article is based on the VCCC alliance webinar 'Cancer and COVID-19 in Victoria: unpacking the complexities of providing palliative care services during a pandemic'.  It is a summary and interpretation of the content and does not represent the views of the presenters or hosting body.

Health care professionals are invited to subscribe to the VCCN: https://www.viccompcancerctr.org.au/victorian-covid-19-cancer-network/

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11 Sep 2020
2 minute read

David Deutscher

On the past and future of VTS

When talking to colleagues or patients of David Deutscher, invariably three traits will be used to describe him. One is his gifted touch with people under his care. ‘You can't walk anywhere on the street with David. We [were recently] in a restaurant and he knew half the people there. They all want to say hello. He's just retired as the chair for the Committee for Ballarat as well. He's very well regarded around town,’ says Alan Crouch, an old friend and prior patient.

On this observation, his former colleague, Joanne Gell of GICS, concurs. ‘Patients love him. In a non-COVID world, you can’t get coffee with him without being interrupted six times by previous patients and family members of patients. He is deeply interested in what everyone has to say.’ David himself comments, ‘Quality care is dignified care, and that requires personal, spiritual and psychological support as much it does medical and technical import. I've always tried to balance these paradigms. So, when I walk down the street, people can be pleased with the journey we have travelled together.’

David adds, ‘The important thing is to listen to patients. What they think is a problem and what we think is a problem may not be the same. So, it is very important to listen. Take the patient history, do a proper exam, and listen to what the patient tells you, what they ask you to do.’

Of his work and experience with VTS, David singles out consumer input as one of the key areas to continue to grow. ‘What the tumour summits have done is involve the patients. There is advocacy for more consumer input; I think that is really good. Patients’ stories and what their perception of…quality of care is, is just as important as what we [clinicians] think of technical care like comorbidity and mortality rates.’

And it’s advocacy that is the second trait used when defining David. ‘I think it’s really important to emphasise David’s [championing] of regional care. He’s absolutely committed. He is a values-driven man in a regional community and he brought a regional perspective to VTS working party discussions,’ says Gell.

‘I think he's fairly driven. Surgery as a profession provides certain material rewards. [But David’s] always had an obligation to give back in some way or another. He elected to stay practicing in a regional town instead of heading to the big smoke; essentially, where the much bigger rewards are. His commitment to practicing regional medicine and his impact on rural medicine can't be understated,’ agrees Crouch.

‘I was with the summits from about 2016. I think I saw a great idea.. a summit where metro, regional and multidisciplinary teams came together to look at how we could improve cancer services. That was a great intellectual idea. [It] opened doors for communication, [which] is why I chose to get involved. Because there is no question, it is incredibly metro-centric. It is not anyone's fault...but unless there is a voice there for us, then by default the voice is not heard. 

‘Before VTS there wasn't a formal avenue for state-wide multidisciplinary teams to communicate with each other. There is a greater trust between metro and regional now, and the ability to interact at a mature level. There is better feedback from metro and… better input from regions. There is becoming a greater awareness of patient ability to be treated closer to home, and you'd still get good quality care. So, I think metro people are starting to realise that people do prefer to be treated and followed up closer to home. Travelling to the city is onerous for many regional people. It is onerous for rural [people].’ 

This brings us to David’s third epithet as a communicator. ‘David is a very good social entrepreneur. He is a bit like human glue, he brings people together from different backgrounds and perspectives, he navigates that space very well.’ says Crouch.

‘David would say, “I’d like you to come to this meeting,” and colleagues would agree before asking what the meeting was about.’ says Gell. ‘He has a capacity to see the big picture and role [the] ICS and clinicians can play in it. He has an appreciation of the importance of networks for sharing of information and ideas. There is nothing like being in a room with passionate, energised, ‘ideas’ people. David recognises this and the importance of trusting relationships.’ With David stepping down, an important part of VTS is being lost, notes Gell.

‘I’m moving on because I think it’s time for younger shoes to fill the position. [In terms of the future of VTS] I’d like to see the DHHS collect more mature and refined data. I’d like VTS to advocate for making the data more granular and more accessible, for funding good data from the public and private sector. [VTS] helps create better systems so clinicians can work at their peak. It provides an infrastructure; an intellectual and quality space to allow them to perform at their best. I think [VTS] needs to engage students and trainees more. It is my view that at MDM meetings, they are still an adjunct. We need to mature the culture of the MDM so that students and trainees feel part of the team.’ 

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