Medical Forum – August 2024 – Public Edition

Backing our rural doctors Cancer care |

August 2024

Colorectal cancer, ‘chemo fog’, saving the breast, thymic tumours

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EDITORIAL BACK TO CONTENTS

Cathy O’Leary | Editor

Don’t put all your eggs in one basket …there is nothing wrong with offering these so-called egg timer tests, but some of the caveats can be blurred, particularly on the world wide web.

Online shopping is not a passing trend – it’s the new norm for many people.

While I still like the bricks and mortar experience, the convenience and economics of couch-shopping – and I don’t mean buying a sofa – is irresistible.

Increasingly, it is not just a new jacket or the weekly groceries that can be purchased via a few clicks – online shopping is increasingly moving into areas such as healthcare and diagnosis.

A cheek swab can be done at home and sent off for genetic analysis, revealing unknown family across the globe. Scripts, sick leave notes and medication can also be sourced without leaving the loungeroom.

And more recently, at-home egg fertility tests can give young women, worried that the baby clock is ticking, an indication of their egg reserve via their anti-Mullerian hormone levels.

If their AMH appears low for their age, they might be offered follow-up appointments. And no surprises here – it might be suggested that they visit a fertility clinic and consider freezing their eggs in preparation for IVF. We live in a free market and there is nothing wrong with offering these so-called egg timer tests, but some of the caveats can be blurred, particularly on the world wide web.

Like the fact that low AMH levels do not mean a woman will have any issue falling pregnant – with many studies including one in the JAMA Network Open spelling this out in black and white.

The only real test of knowing if you are going to have problems becoming pregnant is to actually try!

Yet a low AMH level could steer anxious young women onto costly fertility treatments when, if nature had just taken its course, they could have become pregnant as easily as anyone else.

As a wise doctor once said, only have a test if the result can affect the outcome!

SYNDICATION AND REPRODUCTION Contributors should be aware the publisher asserts the right to syndicate material appearing in Medical Forum on the mforum.com.au website. Contributors who wish to reproduce any material as it appears in Medical Forum must contact the publisher for copyright permission.

DISCLAIMER Medical Forum is published by Medforum Pty Ltd (Publisher) as an independent publication for health professionals in Western Australia. Neither the Publisher nor its personnel are medical practitioners, and do not give medical advice, treatment, cures or diagnoses. Nothing in Medical Forum is intended to be medical advice or a substitute for consulting a medical practitioner. You should seek immediate medical attention if you believe you may be suffering from a medical condition.

The support of all advertisers, sponsors and contributors is welcome. To the maximum extent permitted by law, neither the Publisher nor any of its personnel will have any liability for the information or advice contained in Medical Forum. The statements or opinions expressed in the magazine reflect the views of the authors and do not represent the opinions, views or policies of Medical Forum or the Publisher. Readers should independently verify information or advice. Publication of an advertisement or clinical column does not imply endorsement by the Publisher or its contributors for the promoted product, service or treatment.

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EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers. Medical Forum has no professional involvement with advertisers other than as publisher of promotional material. Medical Forum cannot and does not endorse any products.

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CONTENTS | AUGUST 2024 – CANCER CARE

Inside this issue 14 20

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FEATURES

IN THE NEWS

10 14 16 20

1

Editorial: Don’t put all your eggs in one basket – Cathy O’Leary

4 6 8

News & views

Cover story: A rural life beckons Rapid rise of fatty liver disease Close-up: Dr Mark Hands GPs critical in melanoma surveillance

LIFESTYLE

In brief Evidence not ideology must lead trans care – Prof Ashleigh Lin

22 Ray of hope for infants with leukaemia

50 Peek inside an artist’s studio 52 Kid Snow packs a punch

– Dr Rishi Kotecha

Cover: Dr Clare Hardie and her family on their Wandering farm – picture by Kirsty Chisholm

25 Getting precise about kids’ cancer 26 Creating safe GP spaces 37 Studying human capability – Dr Joe Kosterich

46 Hearables study

IU M W IN E

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WINNERS TAKE ALL

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& A BO VE

This month we have more tickets up for grabs, with five double passes to the 2024 ST ALi Italian Film Festival which returns to Perth from October 3 to 27, with more details on page 51.

L OW

The winner of our doctors dozen from winery Below and Above is Dr David Manners, and plenty of readers have been off to the movies as winners of two recent film competitions.

To enter, use the QR code on this page or go to www.mforum.com.au and hit the competitions tab.

CONNECT WITH US /medicalforumwa

/medical-forum-wa-magazine

/MedicalForum_

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CONTENTS

PUBLISHERS Fonda Grapsas – Director Tony Jones – Director tonyj@mforum.com.au

Clinicals

EDITORIAL TEAM Editor Cathy O'Leary 08 9203 5222 editor@mforum.com.au Production Editor Jan Hallam 08 9203 5222 jan@mforum.com.au

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Role of pathology in the cancer care pathway Dr Asha Hegde

The hidden link: How obesity fuels cancer fire Dr Imran Badshah

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Clearing the fog: Hidden challenge in chemo treatment Dr Virginie Lam

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Save the breast!

Dr Ran Li

Journalist Eric Martin 08 9203 5222 eric@mforum.com.au Clinical Editor Dr Joe Kosterich 0417 998 697 joe@mforum.com.au Graphic Design Ryan Minchin ryan@mforum.com.au

Colorectal cancer in young adults Dr Stephanie Chetrit

Advances in surgical management of thymic tumours Dr Pragnesh Joshi

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WAGCS Survivorship Clinic Dr Chloe Ayres

ADVERTISING Advertising Manager Ross Bulman 0428 759 076 ross@mforum.com.au Clinical Services Directory Alice Miles 08 9203 5222 alice@mforum.com.au CONTACT MEDICAL FORUM Suite 3/8 Howlett Street, North Perth WA 6006 Phone: Fax: Email:

08 9203 5222 08 6154 6488 info@mforum.com.au

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The global challenge of neurological disorders Dr Jan Ho

Non-operative management of hip and knee OA Dr Arash Taheri

Guest Columns

OUR PRINTER’S ACCREDITATIONS

Environment ISO 14001

This magazine has been printed using solar electricity, and the paper is manufactured with elemental chlorine-free pulps. Both printer and paper manufacturer are certified to ISO 14001, the world’s highest environmental standard.

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Killing cancer in a shot Bidyut Sarkar

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Tongue-tied over baby feeds Dr Sharon Smart & Dr Raymond Tseng

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Navigating cancer path together Tania Harris

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Risks are flying high Professor Ross Baker

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NEWS & VIEWS

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Fairer health care for all Home-based health and aged care provider Silverchain has launched a philanthropic arm to improve access and equity in services.

The Silverchain Foundation was launched at a recent panel event in Perth which brought together health and business leaders to discuss the future of care in Australia.

The panel included WA Health Minister Amber-Jade Sanderson, Silverchain Group chief executive Adjunct Professor Dale Fisher and chair of HBF Diane SmithGander.

It was hosted by the new foundation’s inaugural chair, business and finance expert Heather Zampatti.

“With an ageing population and ever-increasing demands on the Federal Budget, Australia is on the cusp of a care revolution, led by local innovation and new models of care… and the system is under significant pressure,” Ms Zampatti told the event.

“The latest Intergenerational report highlighted the ageing population, digital transformation and rising

Burns biobank hits a high The Fiona Wood Foundation’s Children's Burn Injury Biobank has reached a milestone, having recruited 400 families into the study.

The paediatric biobank is believed to be the biggest and most comprehensive collection of biological samples in children and their families after a burn injury anywhere in the world, with the help Perth Children’s Hospital staff.

Stool, urine, blood and hair samples help researchers to better understand the impacts of burn injuries beyond the visible scars.

There are often physiological and psychosocial after-effects from minor and major burns that can profoundly affect a child's quality of life.

The next phase of the biobank project will be to develop a data platform where researchers can curate and safely story data sets from the samples collected.

Together, the biobank and data platform have the potential to move research from bench to bedside.

Cost of hypnotherapy Hypnotherapy could offer benefits to cancer patients, but more work is needed to educate healthcare professionals, according to an Edith Cowan University study.

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demand for care and support services as three of the major forces affecting our society in the coming decades.”

Professor Fisher said it was important for State and Federal governments to work with non-government organisations on evidence-based initiatives that reduced the pressure on the tertiary hospital system and kept people safe and well in their own homes.

ECU PhD student Malwina Szmaglinska said hypnotherapy in a clinical setting looked very different to what was done as entertainment for an audience. For cancer patients, hypnotherapy could offer benefits including managing nausea, pain, anxiety, depression and increasing the quality of life.

“For clinical use, hypnotherapy entails a hypnotherapist speaking to a patient, and is really very similar to meditation,” Ms Szmaglinska. “It is very nonthreatening and non-invasive, and it has no side effects.”

It could also empower patients by teaching them skills such as selfhypnosis, helping them to manage symptoms and improving their overall well-being.

While contemporary cancer treatments had contributed to increased survival rates, they were often accompanied by side effects including nausea, fatigue and poor quality of life.

“There is a largely untapped potential not only to improve patient quality of life, but also to influence disease progression in a positive manner by more effectively addressing psychosocial dimensions of care,” she said.

But despite the effectiveness of hypnotherapy in managing complex symptoms and its inclusion in

the list of effective mind-body techniques by Cancer Council Australia, hypnotherapy was not widely used in cancer care.

“In addition to a lack of education around hypnotherapy, the treatment is also quite expensive.

While counselling and psychology sessions are often covered by Medicare, hypnotherapy is not.

Conversely, hypnotherapy is often cheaper than counselling or psychology, and you would commonly require fewer sessions.

“But because it is not covered

by Medicare, it is a big capital outlay, especially if patients are going through quite expensive treatments.”

She said future studies will investigate attitudes and possible misconceptions among healthcare providers that could act as obstacles to the use of hypnotherapy as a complementary treatment in cancer care.

Calls for better diabetes support Diabetes WA wants better access, subsidised technology and preventative measures in wake of the recent Federal inquiry.

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Role of pathology in the cancer care pathway Pathology is critical in the cancer care patient journey, influencing every step from screening and diagnosis to treatment planning and monitoring.

Pathologists are at the forefront of cancer research by contributing to the discovery of new diagnostic markers, therapeutic targets and treatment strategies through molecular and genetic mechanisms that have led to the development of novel therapies and diagnostic tools.

In the context of cervical cancer care, the involvement of the pathology team is crucial for accurate detection of abnormalities, early intervention and effective management for those at risk of or diagnosed with cervical cancer.

Our expertise ensures the effectiveness of screening programs in reducing the incidence and mortality associated with preventable disease.

Quality pathology services are essential to interpret HPV (Human Papilloma Virus) tests, liquid based cytology and cervical biopsies in order to prevent or detect cases early.

Once diagnosed, pathology results are central to guiding treatment. For example, a 46-year-old woman had a positive HPV test in September 2023. Reflex cytology showed possible high-grade squamous intraepithelial lesion (HSIL), confirmed by cervical biopsy in May 2024. This precancerous state was treated with loop electrosurgical procedure (LLETZ) in June. Pathological assessment of this specimen not only confirmed her precancerous state, it also reassured the treating doctor regarding complete excision and negative margins.

We are all aware that cervical cancer is preventable and curable as long as it is detected early and managed effectively. Elimination is within reach with timely commitment and action.

Pathology laboratories play a major role in this regard by offering screening, diagnostic and monitoring services.

GPs can enroll in Clinical Labs Cervical Screening Audit Program, with RACGP CPD accreditation.

Clinical Labs offers a wide range of services for cervical cancer screening and diagnosis starting from HPV

By Dr Asha Hegde MBBS, MD Pathology (India)

Registrar – Anatomical Pathology screening test, reflex liquid-based cytology (LBC), participation in colposcopic meetings, histology tests for cervical biopsy, LLETZ biopsy, hysterectomy specimens and involvement in multidisciplinary team meetings.

HPV screening tests: We conduct thousands of HPV screening tests in a month which include hospital-based collections and self-collect clinic samples. Our goal is to provide HPV test results with a turnaround time that enables prompt follow-up and treatment for individuals with abnormal findings. Our laboratories have made significant investment towards advanced testing technologies such as state-of-the-art molecular PCR DNA testing to provide accurate and timely screening results.

Reflex LBC triage: HPV positive cases undergo reflex cytology. Highly skilled cytology scientists screen and report.

Cytopathologists further assess and validate cases with abnormal test results, as these patients require specialist referral, colposcopy and biopsy.

Cervical biopsy /LLETZ / CONE biopsy / hysterectomy: Specialist teams decide treatment such as LLETZ/ cone biopsy or hysterectomy, depending on the nature and extent of

the disease. A highly-trained and skilled team of scientists cut, process and stain these complex specimens and present slides to the pathologists. Our experienced pathologists assess the nature and extent of the disease along with the margin status. Challenging cases are submitted for peer review and case consensus meetings.

Multidisciplinary team meetings (MDT): Pathologists participate in colposcopic meetings and tumour conferences. These meetings are conducted to discuss and plan case management or review cases with discordant clinical and laboratory results. Clinical diagnosis, radiology findings, cytology and histology results are discussed to aid decisionmaking on initiating or changing the treatment plan to provide optimal care.

Pathologists further review all cases for the meetings to ensure accurate diagnosis.

The role of pathology in cancer care is multifaceted and indispensable.

It is integral to every step of cancer management. The collaboration between pathologists, oncologists and other healthcare professionals ensures that patients receive the most precise and effective treatments, highlighting the critical importance of pathology in the fight against cancer.

Meet our new pathologists Dr Natalie Dixon

Dr Marissa Muller

BEcon BA MBBS (Hons Class 1) FRCPA IBCD

MBChB (UL) MMed (Path) Anatomical Pathology (UP)

Areas of Interest: Breast Pathology, Dermatopathology, Gastrointestinal Pathology, Gynaecological Pathology, and Medical Education.

Areas of Interest: Breast Pathology, Cytopathology, Gastrointestinal Pathology, Gynaecological Pathology, Haematolymphoid Pathology and Soft Tissue Pathology.

Specialty: Anatomical Pathology

Specialty: Anatomical Pathology

Building Better Partnerships

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NEWS & VIEWS

The 2023 WA Australian of the Year and Perron Institute researcher Professor Samar Aoun has been given a lifetime achievement award for her work in motor neurone disease.

Asthma WA, which turned 60 last month, has changed its name to Respiratory Care WA.

Former HBF chief John Van Der Wielen has joined the board of directors for global pharmaceutical holding company Bridgewest Perth Pharma.

NeuroKids has been awarded a three-year grant from the Stan Perron Charitable Foundation to establish a new paediatric neuronursing service in Bunbury.

continued from Page 4 The Australian Government report into the State of Diabetes Mellitus in Australia 2024 showed the scale of the nation’s diabetes epidemic and that the condition had many complex causes.

The report contains 23 recommendations that cover a range of issues, such as diabetes screening, access to diabetes technology and medication, diabetes research and data and diabetes care for at-risk groups.

Diabetes WA CEO Melanie Gates said key takeaways from the report were the need for greater subsidisation of life-changing technology, better access to diabetes support and services, and more focus on prevention and education “We have been calling for greater access to vital diabetes technology, including continuous glucose monitors (CGM) and automated

insulin pumps because we know the difference these vital technologies can make to people living with diabetes,’’ she said.

The report recommends increasing CGM access for people living with type 1 diabetes, and for the first time considers expanding subsidised access which would benefit the 28,000 West Australians with type 2 diabetes who need insulin injections.

Ms Gates also welcomed the report highlighting the importance of telehealth services such as Diabetes WA Telehealth, which provided support for people living in rural and remote communities, who otherwise might be denied care.

Healthy hormones help A new website, Healthy Hormones, has launched with the aim of changing menopause care in Australia. Created by three GPs continued on Page 9

Low-cost psych help New student-led counselling services at Edith Cowan University’s Health Centre Wanneroo are aimed at addressing a critical need in Perth's northern suburbs.

The affordable services also provide valuable real-world experience to ECU's final year Master of Counselling and Psychotherapy students.

Rural Health West and the WA Country Health Service have recognised paediatric otolaryngologist Clinical Professor Harvey Coates for 40 years of service.

Counselling is guided by specialist couples-and-family therapists who are also senior clinicians and lecturers in ECU’s counselling program.

Counselling is available for individuals, couples and families, teenagers and children aged six years and over. It can address issues such as difficulties through life transitions, emotional issues, loneliness and isolation, grief, loss and bereavement, parent-teen conflicts and school or friendship-related challenges.

Student counsellors practise according to the Psychotherapy and Counselling Federation of Australia’s standards.

Academic lead Dr Sonam Pelden said an ECU research project in 2020 highlighted a significant need for counselling services for children and families in Perth’s northern suburbs.

Edith Cowan University has named Western Sydney University's senior deputy vice-chancellor Professor Clare Pollock as its new vice-chancellor from September.

“Suburbs including Clarkson, Alkimos and Yanchep were identified as having a high demand for services yet faced low service provision, and this continues to be the case,” Dr Pelden said.

Fees range from $10 for casual workers, students and unemployed, $20 for part-time workers and $30 for full-time workers.

Danielle Hayman is a final year student of ECU’s Master of Counselling and Psychotherapy course and is one of the counsellors at the ECU Health Centre.

She said the practical experience provided valuable exposure to a diverse group of clients experiencing a variety of challenges.

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IN BRIEF

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passionate about women’s health, it offers free online education, support and networking for healthcare providers.

Protecting the blood-brain barrier

Members can access a range of evidence-based resources, including handouts, prescriber guides, and a library of books, podcast and articles.

Researchers at the Perron Institute and UWA have found a set of cells that can protect blood vessel structure in the central nervous system (CNS).

The platform features a dynamic discussion forum, where practitioners can share cases and seek advice on menopause care. It will also host regular webinars and online events to keep members up to date. More details at www. healthyhormones.au/healthprofessionals.

Professor Minghao Zheng, head of Brain and Bone Research Axis, said his team had identified a set of astrocytes that could control the integrity of the blood-brain barrier.

continued from Page 6

Mental health checks for kids Mental wellbeing needs to be part of children’s health checks and must be funded, according to the Royal Australian College of GPs. The college has provided feedback to the National Mental Health Commission on draft national guidelines for including mental health and wellbeing in early childhood health checks.

RACGP president Dr Nicole Higgins said mental health checks were essential, as was early intervention, given Australia was in the grip of a youth mental health crisis.

A recent Beyond Blue survey had found that one-third of Australian parents with primary-school aged children were seriously concerned about their child’s mental health, with one in three extremely concerned.

“GPs are the most visited health service in Australia and they’re at the frontline of mental health care – more than 22 million Australians visit a GP for essential healthcare every year, including mental health care,” Dr Higgins said.

“And we are seeing more patients with mental health concerns. The proportion of GPs reporting mental health among their most common reasons for a patient consult rose from 61% in 2022 to 72% in 2023.

“The RACGP is calling for funding for universal annual children’s health checks for the first 2000 days, as this is a critical period which sets a child up for life.”

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NEWS & VIEWS

The blood-brain barrier is a network of blood vessels that supplies essential nutrients to the brain and protects it from circulating toxins and pathogens.

With age, or in brain disorders, the function of the blood-brain barrier is reduced.

The newly discovered subset of astrocytes expressed a protein found in bone tissue called dentin matrix protein 1 (DMP-1). These cells generated ‘end feet’ and transferred mitochondria to endothelial cells which line the blood vessels of the CNS. “Reduction in the function of these astrocytes inhibited mitochondrial transfer and caused leakage of the blood-brain barrier,” Professor Zheng said.

“Mitochondrial transfer from astrocytes to blood vessel cells was identified as crucial to the maintenance of the blood-brain barrier.

“Our findings give new insights into the cellular framework that underpins the breakdown of the blood-brain barrier that occurs in ageing and disease and provide a target for the development of treatment regimes.”

Chemo predictor Curtin University research to develop an early diagnosis tool predicting how cancer patients will respond to chemotherapy has received a significant funding boost.

Almost half a million dollars from the Innovation Seed Fund will be used to create a diagnostic test to identify patients who will benefit from platinumbased chemotherapy, which is commonly used in combatting advanced cancers, but often has poor outcomes.

Researcher leader Dr Yu Yu from Curtin Medical School and the Curtin Health Innovation Research Institute said ineffective therapy affected up to 1500 people in WA a year and more than two million globally.

“Unfortunately, up to half of all patients do not respond to platinum-based chemotherapy and the goal of this project is to provide clinicians with a tool that accurately predicts responses using biopsies at the onset of treatment,” Dr Yu said.

“This diagnostic test, known as ChemoDx, will enhance clinical decisionmaking, reduce unnecessary adverse effects and potentially improve survival rates by paving the way for tailored first-line treatments.”

The project is initially focusing on ovarian cancer, one of the deadliest cancers with a high incidence of drug resistance and late-stage diagnosis.

“Drug resistance is a significant barrier to successful cancer treatment and the inability to predict platinum resistance exposes patients to chemotherapy side effects without therapeutic benefit and weakens the immune system,” Dr Yu said.

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GUEST OPINION

Evidence not ideology must lead trans care Editor’s note: We received several responses to a guest opinion piece by Dr Luke Torre in the July edition, in which he raised his concerns about the use of puberty blockers. Some readers supported his views; others said it was offensive and inaccurate and Medical Forum should not have published it.

We encourage respectful debate, and this is a highly relevant issue being weighed up and debated around the world by doctors and the wider community.

Dr Torre’s piece was not presented as clinical advice, nor as news. It was very clearly labelled on each page as his views. We stand by our decision to publish it.

This month we are publishing a response, which gives a differing opinion.

Dear Editor, I am writing regarding the recent Guest Opinion piece by Dr Luke Torre in the July issue of Medical Forum magazine.

This was brought to my attention by a concerned member of the Australian Professional Association for Trans Health (AusPATH), a national peak body representing, supporting and connecting those working to strengthen the health, rights and wellbeing of all trans people.

Among our membership we count over 600 members from a wide range of professionals and clinicians, and I write on behalf of AusPATH. While Dr Torre has a right to express his view and can do so from the safety of an opinion column, I am deeply concerned at the lack of clarification from Medical Forum about the problematic nature of the American College of Paediatricians.

Though only his opinion, the suggestion put forward by Dr Torre that WA should align itself with the American College of Paediatricians beggar’s credibility.

Firstly, Dr Torre is not referring to the august American Academy of Paediatrics, the largest, most distinguished professional association of its kind in America. He is referring to the faith-based American College of Paediatricians, an organisation that frequently muddies the water between belief and medicine, singling out both trans-based care and reproductive rights to be ended.

The beliefs of the American College of Paediatricians diverge significantly from every other major medical body in the world, including the American Academy of Paediatrics, and they support evidence-based medical practices only when it aligns with their own beliefs.

One must only do a quick google search to recognise its illegitimacy.

Indeed, the Southern Poverty Law Center defines it as “a fringe antiLGBTQ hate group that masquerades as the premier U.S. association of pediatricians”.

I would like to make it clear to your readers that support for the right to medical gender affirmation in minors has been demonstrated in statements by the Australian Medical Association, American Medical Association, American College of Physicians and many other reputable colleges around the world. It has also been strongly supported by the American Academy of Pediatrics, the legitimate academy of paediatricians in the US with over 61,000 members.

After reading Dr Torre’s opinion piece I urge the WA medical community to maintain its commitment to evidence-based practice and to distancing itself from organisations like the American College of Paediatricians. There is no place in Australia for them.

The community can be rest assured that WA children and adolescents are being cared for with respect, caution and vigilance, and that fully informed consent is sought from the child and family before any medical intervention is provided.

Professor Ashleigh Lin AusPATH President on behalf of the AusPATH Board – References on request

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A rural life beckons Being able to train in rural areas is not only critical to keeping doctors in the bush – it also affects their choice of speciality.

By Cathy O’Leary Medical specialists who had the chance to train in rural areas are almost three times more likely to choose to work there after finishing their training, according to an Australian-first study.

Led by Notre Dame University, the study of 1220 medicine graduates from nine Australian universities also showed the impact of doctors’ specialisations on their decision to work in rural areas later in their careers.

Published in BMJ Open, the study’s findings come amid a critical shortage of doctors in rural, regional and remote areas of Australia, with both general practitioners and other medical specialists in short supply.

Picture: Narrogin GP Clare Hardie with her family on their Wandering farm.

Photography: Kirsty Chisholm

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COVER STORY

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COVER STORY The Notre Dame study found about 30% of GPs – the specialty that gives doctors the opportunity to do most of their training in rural areas – were practising in the country 10 years into their careers.

But only 10% of other medical specialists such as psychiatrists or paediatricians, and 15% of surgical specialists, ended up in nonmetropolitan areas a decade after graduation. These specialists do most of their training in the city.

Lead author and researcher from Notre Dame’s Wagga Wagga Clinical School, Dr Alexa Seal, said meeting the medical workforce needs of rural Australians continued to be a major challenge.

Health Alliance and the Wheatbelt East Regional Organisation of Councils.

That program was developed in direct response to the acute doctor shortages in regional WA, which has one of the heaviest reliance on overseas-trained medical graduates, by providing first-hand experience of medicine in a rural community.

While some medical students already harbour a strong interest in rural medicine before medical school, others can develop an interest through rural immersive experiences as part of Rural Clinical School placements and other rural placements.

“This study reinforces the impact of rural training pathways on a doctor’s longer-term work location,” she said. “Specialist training needs to be expanded to support more rural training opportunities for doctors outside general practice because we know that rural exposure is associated with the likelihood of living rurally in the future.”

Changing lives

According to the Australian Medical Association, research continues to show rural Australians have higher rates of hospitalisations, death and injury, and poorer access to primary health care than people living in major cities.

Brisbane-born and a self-described “city girl through and through,” she was doing her Rural Clinical School Placement in Narrogin in 2015 when she met a farmer who would change the course of her life.

There are seven times fewer specialists in remote areas than in metropolitan areas, leaving many patients with no choice but to travel extensively – often with significant financial and familial burden – to attend appointments.

The Notre Dame research built on two earlier studies on the same group of medical graduates from the class of 2011 – one that looked at their practice location after five years and another after eight.

It found the number of specialists working in regional, rural or remote areas increased from 15% at five years after graduation, to 19% at 10 years. This is mostly attributed to non-GP specialists moving to the country after finishing their training in the city.

The study’s findings also underline the value of rural immersion, such as that offered by the Wheatbelt Medical Student Immersion Program – a collaboration between Notre Dame and Curtin universities, Rural Health West, WA Primary MEDICAL FORUM | CANCER CARE

For Notre Dame graduate-turned GP obstetrician Dr Clare Hardie, the decision to work in WA’s Wheatbelt was born out of a rural stint during her third year of studies.

“I had an interest in rural medicine, and I jumped at every opportunity at my rural medical school in Northam,” she says.

The pair hit it off and Dr Hardie made the decision to join her nowhusband Brendon Gilbride in the town of Wandering, but before that could happen, she had to do most of her obstetrics training in Perth.

She was grateful to be able to finish her training under a mentorship program in Narrogin but admits the move from being well-supported in the city to working far more autonomously in a country hospital was daunting.

“For me it was probably a combination of meeting my husband at the right time, and working rurally and loving it, so it was a case of killing two birds with one stone,” she told Medical Forum.

“And at Notre Dame, rural medicine is ingrained from day one of medical school, with case studies to problem solve often based rurally, and the university is really directed at creating rural generalists, so that has an impact by encouraging us to go through third year Rural Clinical School immersion and getting us back out into the country.”

With a farmer husband and two young sons – four-year-old George and two-year-old Henry – she says life is now very busy – “we’re absolutely in the thick of it.”

Dr Hardie is now the only local obstetrician in Narrogin, with the on-call service run by locums.

“I am here because of the Rural Clinical School and all of my GP training could be done regionally, but not the obstetrics,” she said.

“When I came there were two obstetricians, but they have both since left, so if I was to go, there would be no one here permanently to replace me.

“That continuity of care is so important. If you see a woman throughout her pregnancy, you have automatic rapport in the birth suite – and she has trust in you – which makes the birth experience more positive.”

She has also learnt to deal with the challenges of triaging patients to work out who really needs to be seen.

“I’m aware that if I see one patient too much, then that takes away from another patient. And while that’s partly because I do limited hours anyway, it is also because there isn’t anyone else in town who is practising, so they might be retired or they’re not credentialled to deliver.

“If you’re relying on locums, these women are relying on someone they have never seen before during the most special time in their life when their baby is being delivered.”

Four years into her job in Narrogin, Dr Hardie is now starting to see some mothers for their second babies, which is one of the most rewarding parts of her work.

“I seem to get hit up at Coles a lot now,” she said. “Every time I do my click and collect, I run into a mum who is eager to show off their baby to me.

“You get that because it’s a small town. You’re seeing the same patients continually, you see them for the birth and then a few years later you get to do it all again.”

She said there were currently two GP clinics and about 10 doctors in Narrogin, and that was a respectable number. continued on Page 13 AUGUST 2024 | 11

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A rural life beckons continued from Page 11 “During COVID we really struggled with very limited doctors, and it was definitely more stressful then, with patients waiting six weeks to get in to see us, when you just shouldn’t be waiting six weeks to see a GP,” she said.

The Notre Dame study comes hot on the heels of a position paper by Australia’s peak medical school deans’ group, with 25 recommendations to turn around the struggling rural health workforce.

That includes encouraging a rural-first training model, with metropolitan-based training being the exception rather than the rule.

Deans advocating Medical Deans Australia and New Zealand argues that non-GP specialty colleges need to consider how training could be restructured to allow more opportunities for rural doctors, with rural generalism on track to become a fully-fledged specialty.

According to the association, 7% of doctors in training listed rural generalism as their first preference of future specialty in 2023 – a rise of more than two percentage points since 2021. General practice, meanwhile, was first preference for about one in 10 students.

The working group which wrote the position statement had representation from WA, including the Rural Clinical School of WA. It noted that in Australia in 2020, there were 309 medical practitioners per 100,000 population in major cities, compared to 273 per 100,000 population in outer regional, and 223 per 100,000 population in very remote Australia.

Among Australia’s 2022 graduating cohort, just under 40% of domestic medical graduates indicated a preference for future practice outside capital cities, and this increased to over 72% for students from a rural background.

Similarly, almost three quarters of graduates who undertook a rural placement for more than a year indicated a preference for future MEDICAL FORUM | CANCER CARE

careers outside capital cities, irrespective of their rural origin.

The deans’ association said the key going ahead was to adopt a flipped model of training where learning takes place in and for rural communities, with rotations to metropolitan or large regional hospitals only if required.

In another recent development in rural training, the Rural Generalist Pathway WA has developed a tool known as the Career Navigation Record to help trainees through each stage of their rural generalist training.

The electronic record follows each trainee documenting their aims and the outcomes of their career discussions.

Trainees receive personalised career advice and mentoring, and each one is paired with a dedicated director of clinical training to help them work towards fellowship and beyond.

More than rhetoric Meanwhile Dr Hardie says there are still many logistical challenges of rural medicine, and despite some of the rhetoric about support for training doctors and those

wanting to upskill, when push came to shove, it was not always forthcoming.

“One thing I’m hearing is that a lot of genuine rural doctors want to upskill and bring back their skills to the communities that they’re already based in, but the support in city hospitals where it needs to be done is just not there,” she said.

“When I was going through my training, there was a specialist obstetrician who really encouraged us to do GP obstetrics and go rural.

“She was an advocate for us at KEMH in that she gave us access to good jobs like 10 weeks straight of caesarean sections, and in my case, experience that would help me set up in Narrogin. But she’s left now and I’m not sure that sort of advocate is still there in the big hospitals.

“And that’s really sad because if we want to get people with specialist skills out to rural areas, we need the city to be onboard. That means clear training pathways, and priority for those who are genuinely regional as opposed to someone who has no interest in going rural.”

AUGUST 2024 | 13

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FEATURE

The rapid rise of fatty liver disease As diabetes rates rise, the risk of fatty liver disease increase, so new guidelines will help GPs navigate the treatment pathways for their patients.

By Cathy O’Leary New Australian guidelines to help GPs treat fatty liver disease are expected to be released in the next few months, amid rising rates of the condition and the need for clearer referral pathways.

The Gastroenterology Society of Australia (GESA) will soon launch a consensus statement on the assessment in primary care of non-alcoholic fatty liver disease (NAFLD), also known as metabolic dysfunction-associated fatty liver disease (MAFLD).

NAFLD involves the build-up of fat in the liver, which can affect the organ’s function and lead to scarring or fibrosis. In some cases, it can also lead to liver cancer.

The condition affects about 5 million Australians but is typically asymptomatic until the late stages.

And the incidence is rising, with a disease burden that is likely to affect 7 million people by 2030.

Although most people with NAFLD do not develop complications, it is very common in people with diabetes, and is usually asymptomatic and often not 14 | AUGUST 2024

diagnosed. Diabetes affects about one in 20 Australians, with 15% of those living with the risk of serious health effects from fibrosis of the liver.

Despite the concerning increase in rates, hepatologists are worried that there is not enough awareness of the condition.

GPs facing a wave

its complications, and should be referred for specialty assessment,” Professor Adams told Medical Forum.

“These patients need liver fibrosis assessment using specific fibrosis detection tests such as FIB-4, Hepascore or elastography, as standard liver tests and ultrasound are insensitive.

“Upcoming consensus recommendations for the assessment of NAFLD in primary care will be released in the coming months to help GPs in their assessment of these patients.”

University of WA consultant hepatologist Professor Leon Adams, who was a co-chair on the GESA steering committee which led the recent review, says primary care doctors are now seeing big numbers of patients with NAFLD. One of the challenges was to identify those patients likely to develop significant liver morbidity.

When it comes to new treatments, experts argue there is promise, including in the use of therapeutics.

But lifestyle measures remain the mainstay treatment and are adequate for most patients with NAFLD.

“We need to identify those patients with ‘silent’ advanced liver fibrosis who have an increased risk of developing cirrhosis and

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FEATURE steatohepatitis (NASH) and fibrosis,” Professor Adams said.

“Otherwise, there are numerous GLP-1 receptor agonists and co-agonists which are looking promising.”

Research recently published in the Medical Journal of Australia looked at the incidence of decompensated cirrhosis and associated risk factors in people hospitalised with NAFLD or NASH, with or without cirrhosis.

New light shed The QIMR Berghofer study used data from more than 8000 Queensland residents aged 20 years or older admitted to Queensland hospitals with NAFLD or non-alcoholic steatohepatitis between 2009 and 2018.

The researchers described the rate at which NAFLD progression occurred in people with diabetes and cirrhosis as alarming, with 37% developing liver-related complications within a decade.

In patients diagnosed only with diabetes, almost 10% developed liver-related complications within 10 years.

“One in five people with diabetes mellitus have clinically significant hepatic fibrosis,” the authors wrote.

“The greater risk of progression to cirrhosis decompensation in people with both NAFLD and diabetes mellitus has important consequences for the future burden of NAFLD-related disease in Australia”.

In other comparable countries, NAFLD has become one of the most common chronic liver diseases, affecting 25-45% of adults in the general population and up to 70-90% of people with obesity or type 2 diabetes.

Professor Patricia Valery, QIMR Berghofer Cancer and Chronic Disease Group Leader and coauthor of the study, said the condition was of particular concern because of the steep rise in obesity.

The research highlighted the critical need for doctors to be more vigilant with early detection and monitoring of liver complications in patients with diabetes and obesity.

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A rise in Australians with diabetes and obesity was coinciding with an increasing number of people diagnosed with NAFLD, many aged in their 20s and 30s. Those with NAFLD, especially in conjunction with diabetes, were at risk of progression towards conditions such as cirrhosis, liver cancer and liver failure.

Professor Valery said data on the issue, particularly in Australian patients, was lacking.

“Given the greater risk of developing serious liver complications in people with diabetes, identifying advanced fibrosis and providing appropriate interventions to avert disease progression is vital,” she said.

“We want this data to alert all clinicians to the fact this is a growing problem and while they are managing patients with diabetes, obesity and metabolic syndrome, they also need to be vigilant in screening for NAFLD as well.”

Lifestyle changes and the management of metabolic comorbidities were the only treatments for NAFLD at present, she said.

While to date there was no approved medication to treat NAFLD, new diabetes medications used in patients with NAFLD and diabetes were showing encouraging results in reducing the progression of the liver condition.

Professor Valery said improving early recognition of the condition was still paramount, particularly in those most at risk, such as people with type 2 diabetes, and this was recommended in the forthcoming national guidelines.

QIMR Berghofer Clinical Director and hepatologist Professor Elizabeth Powell said the research findings would help clinicians in the field as well as other health organisations.

“This research is an important step in documenting the significance of NAFLD which is likely to become an even bigger burden on health care in the future,” she said.

Guidelines coming According to the Gastroenterology Society of Australia, metabolic

dysfunction-associated fatty liver disease (MAFLS) is the most common liver condition in Australia and worldwide and is often encountered in general practice.

The incidence of cirrhosis and hepatocellular carcinoma (HCC) related to MAFLD was increasing, and a standardised evidence-based approach was needed to identify and assess these patients.

GESA’s consensus statement, which was open for consultation until July 25, details 21 evidence-based recommendations to help primary care health professionals in the diagnosis and assessment of liver disease and comorbid conditions in patients with MAFLD. The society says the new guidelines will help determine the severity of liver disease and assess underlying comorbid conditions in patients with MAFLD, and thereby guide appropriate referral pathways for specialist care and monitoring strategies.

The document was developed by experts in hepatology, general practice, endocrinology, cardiometabolic disease, clinical biochemistry, nursing, implementation science and public health – and reviewed by consumer representatives – including: • Australasian Association for Clinical Biochemistry and Laboratory Medicine • Australian Diabetes Society • Australasian Hepatology Association • Australian and New Zealand Obesity Society • Liver Foundation • National Association of Clinical Obesity Services • Royal Australian College of General Practitioners • Royal College of Pathologists of Australasia The MAFLD assessment guidelines include recommendations that adults with obesity and/or type 2 diabetes mellitus, or two or more metabolic risk factors, should be assessed, and that diagnosis using liver ultrasound should be the first-line test to diagnose hepatic steatosis in people at high risk of MAFLD. Other key recommendations look at how the severity of liver disease should be assessed in people with MAFLD.

AUGUST 2024 | 15

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CLOSE-UP

A lifetime of changes Clinical Associate Professor Mark Hands has recently stepped back from a lifetime’s work in cardiology. He’s now looking forward to what comes next.

By Ara Jansen Don’t say it. Nope! Mark Hands has not retired. He’s more like a FIFO worker who spent 35 years on a swing. Now he’s off shift and pursuing other things – trekking, travelling, farm work, drinking wine, playing tennis, surfing, going to the gym and catching up with friends and family more often.

“While I still love medicine, it’s the right time for me to pursue other things in my life,” says Mark, who recently retired from cardiology. “My wife Ariane, who is also a doctor, is retiring too. It’s the right time for both of us.”

The couple have a farm near Margaret River, where they run cattle, plant trees and escape for holidays, and it’s where they now plan to spend much more time. That is, in between hiking in Sardinia and enjoying a stint on a Greek island in the coming northern autumn.

Sport has played a big part in Mark’s life. A trekker for many years, his first big hike was the Kokoda Trail in 2009, a journey which kicked off his passion and has since included trekking in parts of the French Alps, Bhutan, Patagonia, the Dolomites, Tasmania’s “perfect Aussie wilderness” trails and most recently the Kumano Kodo trail in Japan.

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CLOSE-UP He’s part of a group of friends with diverse work interests – only one other is a doctor – who have been trekking together for 15 years and usually complement their hiking by exploring local food, wine and customs. Ariane is part of the Cullen Wine family, so it’s safe to assume there’s a built-in love of wine for them both.

“I was very lucky because at a young age – my early 30s – we started our private practice actually within a hospital. Believe it or not, it was a novel concept then!”

Mark and Ariane had been acquainted since childhood as their grandfathers were good friends and fathers attended school together. As adults they met properly while working at SCGH and Mark says it has been wonderful to have a partner who understood the rigours and strains of a medical career and what it took to succeed.

“It also meant a lot to me that when we had children, Ari worked parttime so I could continue fulltime. I’m very grateful for that.”

Those familiar with the history of Western Cardiology might recognise Mark as one of the cofounders of the group alongside Professor Barry Hopkins and the late Dr Brian Lloyd. In 1989 Barry and Brian asked Mark to join them, and the group subsequently relocated their private consulting rooms to St John of God Hospital in Subiaco, becoming the first hospital-based private cardiology practice in WA. “I was very lucky because at a young age – my early 30s – we started our private practice actually

within a hospital. Believe it or not, it was a novel concept then!” he says.

“A few years later they asked me to take over the practice and gave me their full support. This was a great gift as, during my 27 years as chairman, I was able to create the kind of work environment I wanted to work in, and to work with colleagues who were like-minded about how things should be done.

“I think this helped us endure as a group for 35 years. We’re lucky because many practices have disbanded, had ownership changes or business collapse. However, being chair from an early age probably affected my work-home life balance as there was so much to do to get things up and running.”

Mark says the innovations in cardiology since the early 1990s have been extraordinary and it remains one of the most rapidly developing and changing fields in patient management.

In 1991 Western Cardiology complemented their 24 hour oncall private cardiology service with non-invasive testing, including the first colour flow Doppler echocardiogram studies offered in private practice in the state.

“When I first started, we would transfer patients to a public hospital because they had what was needed – such as junior medical staff, fully functioning CCU and cath labs. Within five years it was the other way around and we were transferring patients to a private hospital for their care. Since the very beginning we’ve always had an extremely good relationship with the administration at the Subiaco St John of God Hospital.”

On top of that Mark was learning how to be a company director and getting a crash course in business management. He quickly learnt to continued on Page 19

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AUGUST 2024 | 17

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A lifetime of changes continued from Page 17 delegate and engaged a wonderful practice manager, Sue Stark, in 1993. Sue remains the practice’s general manager.

While he’s had an extremely successful career in cardiology, Mark’s medical journey actually began in dentistry. His elder brother chose the field and Mark thought he would follow. He was playing a lot of sport at the time and felt the two would fit together comfortably.

Soon enough though, he realised he wanted a medical career and UWA let him swap across into third year medicine.

At 17, Mark had been more interested in football than making career choices and briefly played Reserves for Claremont. However, once he started studying medicine, his dreams of going further in footy faded away as he made new friends and developed different interests.

“I was never going to be good enough to play for the top league,” he says.

Boston’s Brigham and Women’s Hospital. As an interventional cardiologist, coronary angiography, angioplasty and stenting were his specialties and he’s been party to their fast-moving surgical evolutions.

“Medicine however, had everything.

The impact you can have on people’s lives is part of the incredibly privileged position the job brings, and you have a quite unique relationship with patients.

In interventional cardiology, in particular, it can be almost instant gratification on both sides because they feel better and (hopefully) you have done something worthwhile.

The mix of connecting with patients and the technical work of operating has been a very good one for me.”

Mark’s father was a physics lecturer and mother studied law, but her career was derailed by the law school shutting down during World War II. He says they both gave him the freedom to make his own career decisions.

“When I started training, we’d put someone with a heart attack to bed and watch them for 10 days, hoping they’d survive. By the time I had finished training, we would take that same patient straight to the cath lab and they would mostly go home well in the next day or two.

rotations included stints in intensive and coronary care units, which exposed him to the early days of angioplasty.

During the summer holidays between second- and third-year dentistry, Mark worked in the university’s Anatomy Department, dissecting cadavers for students.

He started to think “that’s interesting” and this seeded the idea of a career in medicine.

“I was a resident just as angioplasty started being done in Perth. Seeing patients coming back from the brink of death was amazing. One of the things I remember from dentistry was using my hands and I liked the physicality of that.

Cardiology offered that, plus being able to connect with patients – a great mix.”

On graduation from UWA he was awarded the AMA Gold Prize as dux in his final year. His clinical

He trained in cardiology at Sir Charles Gairdner Hospital and subsequently spent three years at

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“That development was in the space of three years. The fact that this intervention could have such a favourable effect on a patient was extremely rewarding to us as cardiologists. I still get great satisfaction thinking about it.

“I’ve always been optimistic and reasonably energetic. The word retirement sounds as though you’re going to roll over and die, whereas I want the next stage to be another long, active and interesting journey.”

That long active journey will of course include wine – burgundy being Mark’s favourite, just in case you were thinking of sending him off in style.

AUGUST 2024 | 19

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FEATURE

GPs critical in melanoma surveillance An Australian study has reinforced the value of GPs doing skin checks, after finding a high failure rate for melanoma self-checks – increasing the cancer risk for patients.

By Cathy O’Leary Southern Cross University research shows that many people are unable to recognise malignant melanomas on their own skin, calling into question the effectiveness of national self-detection guidelines.

Only a small percentage of participants studied were able to self-identify either in situ or invasive malignant melanomas (MMs) as a lesion of concern.

Only the more advanced, thicker MMs tended to be red flagged.

Australia is the skin cancer capital of the world, with more than 11,500 Australian men and women diagnosed with a melanoma each year – at least 1000 of the cases in WA. The latest findings are in the paper, Patients poorly recognise lesions of concern that are malignant melanomas: is self-screening the correct advice, recently published in the journal J-Peer.

The study sought to determine the percentage of patients who were able to self-identify MMs as lesions of concern when presenting for a skin cancer examination.

Of the 260 participants whose suspected malignant melanomas lesions were biopsied, 32% were found to be melanomas. Of the malignant melanomas, only 21% of people had correctly been concerned that the suspect lesion was a MM. These melanomas were located primarily on the back (44.4%), shoulder (11.1%) and upper leg (11.1%).

In a ‘sunburnt’ country which embraces outdoor and coastal lifestyles, the research team is calling for the current melanoma screening practices, as

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FEATURE per the Royal Australian College of General Practitioners ‘Red Book’, be revisited to improve patient outcomes.

submitted a key paper to the Federal Health Department asking to fund a review of skin cancer screening guidelines.

In addition, the researchers say national prevention campaigns should include images and primary risk factors for malignant melanomas.

“This study not only demonstrates that GPs in Australia have the ability to diagnose melanomas similar to any expert level internationally but reinforces the message that the government needs to review its melanoma screening guidelines,” Professor Hudson said.

“Early detection of melanoma is crucial to improve outcomes, minimise treatment complexity, and enhance the quality of life for patients,” said project leader Associate Professor Mike Climstein.

“We recommend regular outdoor users – walkers and runners, swimmers and surfers – who are at a much higher risk of melanoma, undergo screening once a year regardless.

“For everyone else, if you either work or exercise out in the sun, particularly during peak ultraviolet radiation (10am to 2pm) or you have a higher risk of skin cancer such as history of melanoma or skin cancer, family history of skin cancer, have fair or freckled skin, have red or fair hair or lots of moles on your body, you should be getting screened every six months by your skin cancer doctor.”

Over the past 40 years, there has been a significant rise in skin cancer rates in Australia, with two out of three Australians expected to develop some form of skin cancer by age 70. Currently, skin cancer examinations are not endorsed in asymptomatic or

Associate Professor Michael Stapelberg, a skin cancer doctor at the John Flynn Hospital Specialist Centre on the Gold Coast, said the findings were sobering.

low-risk individuals in Australia, with only high-risk individuals recommended to undergo regular skin examinations.

The Melanoma Institute Australia suggests that half of patients identify MMs themselves, but the Queensland researchers argue this claim appears to be based on limited Australian data which may not reflect contemporary practice.

They say the consequences of not detecting melanoma early include increased mortality, more aggressive treatment, higher medical costs, lower survival rates and reduced quality of life.

Co-author Associate Professor Jeremy Hudson is a member of an expert group with the Melanoma Institute of Australia that recently

“Based on my experience with patients contributing to this data here on the Gold Coast, many were unaware they had skin cancer.

Interestingly, most of these patients had few risk factors for melanoma, yet still had a melanoma that they were completely unaware of detected during their skin check,” he said.

“The detected melanomas were generally small in size, which could make self-detection even more challenging for these individuals.”

The research team is calling for Australia to consider implementing a national melanoma screening program, like screening for bowel and breast cancer.

But this is not a position shared by groups such as Cancer Council Australia, which argues that while observational studies have shown the benefit of screening for melanoma, there is a lack of highlevel evidence showing a reduction in death, so population screening programs are not recommended.

However, the council advises that people at high risk of melanoma and their partners be shown how to recognise and document lesions suspected of being melanoma, and they should see their doctor for a six-monthly full skin examination supported by total body photography and dermoscopy.

Meanwhile the RACGP recommends that those at increased risk of skin cancer be offered opportunistic clinical skin examinations. They should have a skin examination every 6-12 months, with or without photography, and be encouraged to conduct regular skin self-examinations.

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AUGUST 2024 | 21

A ray of hope for infants with leukaemia Are we finally shifting the dial for babies with leukaemia, asks Perth paediatric oncologist Dr Rishi Kotecha.

Improvements in outcome for children with cancer has been one of the success stories of modern medicine. Considered palliative only 75 years ago, the overall survival rate has now risen to over 80%.

and so while survival outcomes may seem acceptable when visualised on a Kaplan-Meier curve, cancer remains the leading cause of disease-related death in children, claiming the lives of three children every week.

We can attribute this progress largely due to the improvements in multi-modal therapy uniformly delivered through treatment protocols developed by international co-operative trial groups.

In part, this is attributable to several paediatric cancer types that continue to have poor outcomes despite the advances that have been made.

In Australia, more than 1000 children and adolescents are diagnosed with cancer each year,

Infants diagnosed with acute lymphoblastic leukaemia (ALL) before their first birthday constitute a unique group that has proven difficult to treat. Over 80% of cases

harbour a KMT2A rearrangement, which is an aggressive genetic driver associated with treatment resistance and high rates of relapse.

The survival rate for these infants is less than 40%. Welcoming a new baby into the family should be one of the most joyous moments in life, however, the devastation for families faced with such a diagnosis is ineffable.

At Perth Children's Hospital, Telethon Kids Institute and Curtin University, I have been leading research efforts improve outcomes for our youngest cancer patients. Initial global clinical

Getting precise about kids’ cancer A world-first study involving more than 100 cancer researchers and clinicians across Australia, including Perth, has shown that precision medicine can markedly improve outcomes for children with high-risk cancer.

Precision medicine involves the delivery of treatment tailored to the individual child’s cancer, based on detailed genetic analysis of each tumour’s driver genes.

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In a study that is rewriting the narrative for children with aggressive cancers, 55% of children who received personalised treatment as part of the trial achieved complete or partial remission, or had their disease stabilised for at least six months.

The study, led by the Children’s Cancer Institute in Sydney and published in the journal Nature Medicine, included 384 children

with high-risk cancers who, in many cases, had failed to respond to standard therapy.

The children were recruited from every children’s hospital in Australia through the ZERO Childhood Cancer Program, Australia’s national precision medicine program for children with cancer.

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GUEST COLUMN

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GUEST COLUMN trials intensifying chemotherapy achieved the desired effect of reducing relapse rates, but the young babies were shown to be highly vulnerable to the toxic effects of intensive treatment. This led to increased rates of treatmentrelated mortality, thus there was no improvement in overall outcome.

In addition, further research identified an extremely high burden of long-term treatment-related complications in those that did survive, including severe organ dysfunction, neurodevelopmental deficits, psychological issues and endocrine complications. These findings were pivotal in highlighting the need for innovative therapies to improve outcome as well as reduce the burden of long-term side effects.

The advent of immunotherapy in the field of cancer care has provided a watershed moment for infants with ALL. Immunotherapeutic approaches such as blinatumomab – a bispecific T-cell engager – are considered to result in significantly less toxicity than conventional chemotherapy while at the same time having a potent anti-leukaemic effect.

Integration of blinatumomab into the standard chemotherapy backbone for infants with ALL was investigated in a global phase II pilot study.

The primary outcome measure for this study was to assess safety, however, we also observed a remarkable improvement in survival by 30%. Given there have been no significant improvements for infants

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The primary outcome measure for this study was to assess safety, however, we also observed a remarkable improvement in survival by 30%. Given there have been no significant improvements for infants with ALL for several decades, such pivotal findings led to publication in the New England Journal of Medicine.

with ALL for several decades, such pivotal findings led to publication in the New England Journal of Medicine.

These findings have now set the scene for investigating blinatumomab in a larger international phase III trial, which will also establish whether certain cycles of chemotherapy can be replaced by blinatumomab.

Another rapidly evolving field in the treatment of cancer is targeted molecular therapy. We have gained a greater understanding of the mechanisms of leukaemogenesis for KMT2A-rearranged disease.

Significant laboratory research has been conducted to develop and investigate agents which may be able to target the machinery of this driver translocation or its downstream targets.

The addition of drugs which have been identified to be potent and efficacious in preclinical models of infant ALL have been added to the armamentarium of available novel therapeutics and are now poised to enter clinical trials. Collectively, with these recent advances, it finally feels we are now ready to shift the dial for infants with ALL. ED: Dr Kotecha is a consultant paediatric oncologist and clinical haematologist at Perth Children’s Hospital, head of the Leukaemia Translational Research Laboratory at Telethon Kids Institute and an adjunct associate professor at Curtin University. He has been awarded a NHMRC Investigator Grant to continue leading his preclinical research program and international clinical trials to improve outcomes for infants with ALL.

AUGUST 2024 | 23

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GUEST COLUMN

Getting precise about kids’ cancer

continued from Page 23 ZERO is jointly led by the Children’s Cancer Institute and Kids Cancer Centre at Sydney Children’s Hospital and involves cancer research and treatment organisations across the country, including the Telethon Kids Cancer Centre and Perth Children’s Hospital.

length of time a patient lives without their cancer getting any worse.

The study found precision medicine was superior to standard or nonguided therapy, in terms of both clinical response and survival.

The results showed children who received a ZERO-recommended treatment did significantly better than those who did not. In fact, their two-year progression-free survival was more than double that of children who received standard therapy (26% vs 12%), and five times higher than that of children who received an unguided treatment (a novel agent not chosen on the basis of molecular findings).

Children involved in the study received tailored treatment recommended to their oncologists

by ZERO’s experts following detailed genetic analysis. This approach enabled drugs to be better matched to the child’s cancer driver genes, with the analysis often suggesting drugs not normally used to treat that cancer type.

Importantly, the study found that children who received their recommended therapy early in their treatment pathway did significantly better than those who received it after their disease had progressed, suggesting that the sooner a personalised treatment strategy could be implemented, the better the chance of preventing relapse and death.

Children who received the personalised medicine were observed for an average of three years following treatment, with the results showing an improvement in progression-free survival – the

A team led by clinician-researchers Professor Rishi Kotecha and Professor Nick Gottardo, from Telethon Kids Cancer Centre and Perth Children’s Hospital, led the Perth arm of the trial and are also

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involved in the next phase, ZERO2, which has begun expanding personalised treatment to every child diagnosed with cancer in Australia, rather than just those with high-risk cancers.

Dr Kotecha, who is co-head of Leukaemia Translational Research at Telethon Kids, said the newly published results confirmed precision medicine as a valuable new tool for tackling childhood cancer.

“What precision medicine gives us is another avenue with which to tackle these tumours in children, in addition to existing therapies,” Dr Kotecha said.

“It’s effectively a fifth arm that we can now think about using in conjunction with those other therapies to improve cure rates – a tool that gives us further options to guide therapy and provides a lot more information about each individual tumour than we previously had access to.”

AUGUST 2024 | 25

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Creating safe GP spaces Stigma and discrimination according to gender identity is still very much a thing in the WA healthcare system, a study has found.

By Eric Martin Recent Curtin University research commissioned by the group Living Proud has revealed that despite efforts to improve equity, significant challenges are still faced by LGBTIQA+ people trying to access healthcare.

The study found that ongoing experiences of stigma, discrimination and exclusion continue to affect the health and social outcomes for LGBTIQA+ people in WA, highlighting ongoing lack of action to address health disparities in these communities.

The recent release of The Cass Review, which called into question some of the recent research supporting specific interventions for children and young people, refocussed clinicians’ attention on the issue of gender.

Australia’s response has been mixed, with some researchers throwing their support behind the 26 | AUGUST 2024

findings, whereas others, like Curtin University’s Professor Jonathan Hallett, a senior lecturer at the School of Population health, noted that the national experience with LGBTIQA+ healthcare supported early intervention and a patientcentred approach.

“We have a good record in Australia around high-quality intervention and the use of appropriate things such as puberty blockers, which allow young people to have some time to determine what their identity might be before they have more invasive procedures. But we also know that there are procedures that are important for people to feel aligned to their gender,” Professor Hallett said.

“Talking to mainstream services in healthcare, there was a lot of goodwill to act, and there's certainly been a strategic shift that we have seen in some policies, but what we haven’t been seeing is that necessarily translating into much genuine change.

“It's not ill-will on the part of health practitioners, sometimes it can just be a lack of understanding or awareness, as they haven't had the direct experience to build a link with the varied experiences of people in those communities.”

His latest study, LGBTIQA+ Primary Healthcare Priorities in Western Australia: Insights for Advocacy and Action (2024), showed that the strongest stories were from trans and non-binary individuals, MEDICAL FORUM | CANCER CARE

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FEATURE but people were still highlighting that it was not necessarily outright discrimination impacting their experience of healthcare, rather the assumptions and demeanour that practitioners can exhibit.

“There are issues around LGBTQI+ going to clinics or other health services for issues that are completely unrelated to their sexuality, and then being asked probing questions about gender identity. There were also people whose sexuality may have been medically relevant, but they were fearful to disclose details,” Professor Hallett said.

“One of the clearest messages that emerged was that the biggest barriers to seeking healthcare services were the fear of elimination and having negative past experiences. The older folks that we talked to had awful experiences in their younger days in the 1980s and ’90s - but that's not to say it doesn’t still exist.”

Professor Hallett said there was still stigma and discrimination more broadly in society and it should not be assumed that health services were immune to broader social influences. But there were lists of LGBTQI+ friendly GPs and other health services that circulated between organisations and community members.

“We know that there are wonderful GPs and wonderful health practitioners that are doing important work, but the fact that we need people to be circulating lists indicates that there is still a problem with fundamental universal access to primary healthcare,” he said.

Who's who “If you're not already connected to that list, how do you get that information? You're just hoping that the service provider in your local area might be on that list or know someone who is.”

The purpose of the research was to look at the unique experiences of LGBTIQA+ accessing healthcare services in WA to help inform statebased reforms.

“And in part, we did see that with the scope of regional barriers that exist in WA compared with some other states. But what came out strongly was the importance of community organisations,” he said.

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“We already know that role is vital from work in the women's health movement and Aboriginal controlled medical services.

They have been engaging people with lived experience and the communities in service development, planning and delivery to get better outcomes. However, unsurprisingly but unfortunately, one of the biggest challenges facing these organisations is that the sector is incredibly underresourced, and volunteer driven.

“They provide some of the crucial services that are almost the keystones in the response to health disparities in these communities.

But without long term-funding, and if they are not able to deliver the scope of services required, then these communities are reliant on mainstream contact points to navigate the system.”

Judgment fear He stressed that while LGBTIQA+ did not always have a necessarily unique experience of every health issue, there was real fear that when accessing a service, where the individual needed to disclose personal information about their health, that they were going to get a biased response.

“Health practitioners are professional so it's not always overt. Yet anything that prevents a level of useful disclosure that supports a better health treatment plan is problematic. Especially as sexuality and gender identity are often connected to how individuals experience mental health or sexual health outcomes, and the behaviours associated with it,” he said.

“It’s vital that health practitioners are aware of those contexts where it's important to explore those issues, but you need to do that sensitively and allow your patient to know that it's safe to disclose. It's about collaboratively taking that educational approach to place the conversation in context, but not necessarily making a big thing of it.

“One of the things that came up was ‘trans broken arm syndrome’, which is this idea that when you visit the doctor with a broken arm, suddenly the conversation is about your gender identity, which is totally irrelevant.”

relationships with a primary health care physician.

“To establish that earlier in your life and then have it continue through these experiences is increasingly rare, and that's a real shame because you don't establish the long rapport and trust from which really positive health experiences can come,” Professor Hallett said.

“The healthcare system has been set up to facilitate quick interactions with people, yet it's hard in that short time to get a good understanding of a patient's environment, both in terms of their social connection and all the factors that might influence their health and ability to navigate services or access treatments.

“That means a longer-term relationship with health care practitioners is far more helpful, because you can establish that level of understanding. And one of the really great things about primary healthcare is their understanding of health beyond the clinical, beyond the individual physiology to encompass the community, social, and environmental influences on health.

“Many of the people we spoke to are really in the right circumstances: they are feeling like they're being heard and it's a safe environment to disclose. However, it is also one of those areas where patients often end up bringing quite a large amount of expertise. They have had to become experts themselves because there aren't the cohesive services to provide that. And while that may be uncomfortable for practitioners, it is also an important opportunity as well.

“Finally, there was a lot of discussion around the invisibility of these communities in our data sets and screening tools. The more we can make people feel safe to disclose this information, and collect it, the better we can help our services to tailor programs for specific community needs.

“And as a practice, perhaps we need to think through responses and visual cues that we might have in clinics that present an inclusive space where it is safe to talk.”

Another issue that emerged was that it was no longer common for people to have genuinely long-term AUGUST 2024 | 27

Government of Western Australia North Metropolitan Health Service Cancer Network WA

NOW A SIMPLE BOWEL TEST COULD SAVE MORE LIVES The National Bowel Cancer Screening Program has lowered its age eligibility from 50 to 45.

This change is informed by the latest scientific evidence and aligns with updated clinical guidelines for colorectal cancer.

Learn more at www.cancer.org.au/go/clinical-guidelines-bowel As of 1 July 2024, people aged 45 to 49 can request their first free kit and join the program by: • contacting their GP • calling 1800 627 701 • visiting ncsr.gov.au/boweltest Eligible people aged 50 to 74 will continue to receive a bowel screening kit in the mail every two years.

Alternative access to kits • Healthcare providers can give bowel screening kits directly to eligible patients using the alternative access model. This is in addition to the existing mail out model.

• Providers can bulk order bowel screening test kits for their practice through the National Cancer Screening Register’s Healthcare Provider Portal.

Visit health.gov.au/nbcsp or scan the QR code to find out more.

28 | AUGUST 2024

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NMHS6381_0724

• This approach aims to remove barriers preventing some people from participating in the program.

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Killing cancer in a shot The growing promise of cancer vaccines is tantalisingly closer, according to research scientist Bidyut Sarkar.

A cure for cancer, which is second only to cardiovascular diseases in its contribution to the global burden of disease, has long been a dream.

While no magic bullet is yet in sight, three vaccines for particular skin and lung cancer types have advanced to the last stage of clinical trials in recent months. If successful, these vaccines should be available to patients in the next three to 11 years.

Cancer in every person is different because the cells in every cancerous tumour have different sets of genetic mutations.

Recognising this, two of the vaccines are personalised and tailor-made for each patient.

Oncologists working with pharmaceutical companies have developed these individualised neoantigen therapies.

In individualised neoantigen therapy, the gene sequence of the tumour and normal blood cells are compared to identify neoantigens from each patient, and then a subset of neoantigens are chosen that are most likely to induce an immune response. The vaccine for an individual patient targets this chosen subset of neoantigens.

These vaccines, jointly developed by pharma giants Moderna and Merck, have been shown in trials to be significantly more effective in combination with immunotherapy than immunotherapy alone in preventing both the relapse of melanoma and non-small cell lung cancer after the tumours had been surgically removed.

The vaccines are now being tested on a larger group of patients in phase III trials. The studies are expected to be complete by 2030 for melanoma and 2035 for lung cancer.

The Moderna-Merck cancer vaccine may not be the first to reach the market. The French company OSE MEDICAL FORUM | CANCER CARE

Immunotherapeutics published positive results last September from phase III clinical trials of a vaccine using a different approach for advanced non-small cell lung cancer. Its vaccine, Tedopi, is scheduled to start confirmatory trials, which are the last step before regulatory approval, later this year and may be available by 2027.

Vaccines for pancreatic cancer being developed by BioNTech and Genentech, and for colon cancer by Gritstone, are also showing promising results in the early phases of clinical trials. Like the vaccines being developed by Moderna and Merck, these too are individualised neoantigen therapies based on messenger RNA (mRNA).

There is another kind of RNA therapy also under development that uses small interfering RNA (siRNA) and microRNA (miRNA).

Since 2018, six siRNA-based therapies have been approved by the FDA for the treatment of neural, skin, heart and renal diseases.

Several more siRNA drugs are at various clinical trial stages for different types of cancer and a diverse range of other diseases.

The RNA vaccine for an individualised neoantigen therapy is a cocktail of mRNA carrying the codes for neoantigens — the mutated fingerprint proteins in cancerous cells. For the ModernaMerck study, scientists identified 34 neoantigens per patient. They delivered the corresponding mRNA vaccine cocktail packed in lipid nanoparticles, just like the mRNA vaccines for COVID-19 developed

by Moderna and Pfizer-BioNTech.

When the vaccine is delivered after removing the tumour, it trains the immune system to recognise neoantigens and fight back against the cancer returning. Usually, the body’s natural immune system corrects mutations and prevents us from having cancers.

immune response is insufficient, leading to tumour growth. In individualised neoantigen therapy, these mutations in the tumour cells are used for vaccine development and for training the immune system to fight back against relapse after removal of the tumour.

Recent advances in artificial intelligence are helping identify potential neoantigens and manage personalised therapies. Firstly, tumours and normal blood cells of a patient and their comparison produces a huge amount of data.

The individualised nature of the treatment is probably why it has been more effective in trials than previously unsuccessful RNA vaccine candidates. However, this personalisation is also likely to raise challenges for the timely and costeffective delivery of treatment to populations around the world.

The siRNA and miRNA treatments work in a way opposite to mRNA. While each mRNA in a vaccine carries the code for producing a protein from a pathogen (antigen) or tumour (neoantigen) to train our immune systems against future attacks by the pathogen or tumour, siRNA directly targets the mRNA of the antigen or neoantigen and terminates the production of the protein it codes.

Thus, the effect of a siRNA is more direct and immediate (like a drug), rather than a protection against future attacks (like a vaccine).

ED: Research scientist Dr Bidyut Sarkar is the DBTWellcome Trust India Alliance Intermediate Fellow in the Department of Chemistry at Shiv Nadar Institute of Eminence in Delhi, India.

This article was originally published under Creative Commons by 360info

However, in some cases this natural AUGUST 2024 | 29

Tongue-tied over baby feeds Managing tongue tie in infant feeding requires individual assessment, according to Dr Sharon Smart and Dr Raymond Tseng, who have roles at Curtin University.

Discussion around tongue tie or ankyloglossia division has recently regained prominence with media characterisations ranging from a miraculous intervention to a draconian procedure.

But to move beyond this polarised narrative, it is crucial to contextualise the rise in surgical procedures for ankyloglossia with the concurrent increase in breastfeeding rates.

The World Health Organization recommends exclusive breastfeeding for the first six months of life and continued breastfeeding into the second year and beyond to ensure optimal growth. Over the past decade, global breastfeeding rates for infants up to six months increased by 10% from 38% to 48%.

Consequently, the number of infants referred for assessment of breastfeeding and tongue tie evaluations has escalated. A study conducted at an Australian tertiary hospital reported a 25% increase in referrals for tongue-tie division between 2014 and 2018, although the number of procedures performed remained relatively stable.

This contributes to the general perception that frenectomy surgeries are, perhaps unnecessarily, surging when the reality is increased awareness of ankyloglossia allows more children to be screened, while surgical correction is still reserved only for those cases where it is medically necessary.

Ankylofrenula is a structural limitation of the frenulum tissue within the oral cavity that results in functional impairments, as defined by the International Consortium of Oral Ankylofrenula Professionals.

Ankyloglossia, commonly known as tongue-tie, is a congenital condition characterised by a short, tight lingual frenulum that restricts tongue mobility.

30 | AUGUST 2024

Implications The functional repercussions of ankyloglossia on breastfeeding are well-documented and supported by a significant body of literature. Post-surgical improvements in tongue function during breastfeeding have been substantiated with both objective and subjective measures, and lead to enhanced efficacy during breastfeeding and bottle feeding, decreased nipple pain, increased breastmilk intake, reductions in GERD severity, and improvements in sleep duration and quality.

Early assessment and intervention are critical to prolong breastfeeding duration and mitigate potential functional issues.

For infants experiencing breastfeeding difficulties, parents should seek the expertise of an international board-certified lactation consultant. The IBCLC will conduct a comprehensive history, including prenatal and perinatal

details, assess the infant, and evaluate feeding mechanics.

For bottle-feeding, eating or drinking challenges, families should seek the support of a speech pathologist with expertise in paediatric feeding and dysphagia.

Should feeding issues persist that cannot be addressed with sustained lactation support or speech pathology, or other nonsurgical intervention, the family may be referred to a clinician proficient in tongue-tie evaluation and surgical management.

Clinicians may include physicians, midwives, or dentists with specialised training in the surgical management of ankyloglossia in infants and children. Prompt and accessible pathways to these professionals are essential to support families and sustain breastfeeding.

Delays in treatment can result in unnecessary supplementation, MEDICAL FORUM | CANCER CARE

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The diagnosis of an infant involves a visual examination of the oral cavity, assessing tongue movements, including tongue lateralisation, anterior and midtongue elevation, in addition to functional sucking and swallowing skills. An integrative breastfeeding or feeding assessment is crucial to evaluate the tongue's morphology, mobility and functional capacity during feeding.

Managing & treating The Australian Dental Association, the American Academy of Pediatric Dentistry and the International Consortium of Oral Ankylofrenula Professionals provide comprehensive guidelines for managing frenulum issues in paediatric patients, emphasising a multidisciplinary approach.

The ADA's ankyloglossia and oral frena consensus statement recommends starting with nonsurgical interventions such as optimising breastfeeding techniques and educating parents.

If these measures fail, surgical options such as frenotomy

may be considered to address functional challenges associated with breastfeeding, reflux, and respiratory problems in neonates.

practitioners and advocate for further research to understand and effectively treat frenulum-related issues.

Similarly, the AAPD policy outlines management strategies for various frenulum attachments and emphasises the need for individualised assessment and cautious surgical intervention.

Ankyloglossia has been recognised for millennia, but not all infant cases necessitate intervention. Increasing the number of trained practitioners to provide breastfeeding support and identify ankyloglossia is crucial.

These practitioners must be able to refer cases requiring further assessment and potential treatment to specialists with expertise in neonatal care and breastfeeding support.

The ICAP Practice Guideline for ankylofrenula management mirrors these guidelines in promoting a protocol that emphasises thorough assessment and diagnostic procedures, and the implementation of conservative non-surgical treatments before progressing to surgical intervention, and even then, only for current symptoms, not for prevention of future symptoms.

Frenotomy can improve breastfeeding outcomes for infants with significant ankyloglossia, though it is not always necessary and should not be performed solely to prevent future speech issues.

ED: Dr Sharon Smart is a speech pathologist and academic in the School of Allied Health at Curtin University, and vice-chair of ICAP. Dr Raymond Tseng is a paediatric dentist and a research fellow at Curtin’s School of Allied Health and chair of the ICAP scientific affairs committee.

The authors acknowledge Associate Professor David Todd and Monica Hogan, who contributed to the original publication in The Conversation.

References supplied on request.

All organisations stress the importance of discussing the risks of surgical procedures with

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AUGUST 2024 | 31

Help your patients on their pregnancy journey with Genea Perth’s bulk billed ovulation tracking program.

In the realm of reproductive health, GPs play a pivotal role in recognising and addressing potential fertility challenges.

For women with irregular menstrual cycles or unexplained infertility despite persistent attempts to conceive, precise ovulation tracking can be a crucial first step.

Charting and monitoring ovulation can be a complex process. While manageable for individuals or couples to do on their own, experts have access to more advanced tools and technologies for accurately monitoring ovulation. Utilisin ovulation tracking through a fertility service can also serve as an initial step toward unraveling potential conception-related challenges before considering a referral to a fertility specialist.

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Easy online referrals through Genea GPs can download and complete the Genea Referral Pack online or by calling 08 9389 4200.

After referral, patients then call or email a Genea nurse between days 1-3 of their period. The nurse will provide instructions on when to come in for a blood test and will be available to support and guide patients through the process.

Ovulation reports sent to your practice GPs receive patients’ ovulation reports containing insights into their hormonal status and ovulation cycles, aiding in the assessment and management of fertility issues.

Many individuals experience emotions such as anxiety during ovulation tracking, especially if previous attempts to conceive have been unsuccessful.

When tracking ovulation independently, individuals may lack the support and guidance of healthcare professionals who can provide reassurance, answer questions, and offer emotional support throughout the process.

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Navigating the path together A valuable consultation with cancer patients, and their carers, has offered insight into their paths through the system, says Health Consumers’ Council’s Tania Harris.

A cancer diagnosis is more than the start of a medical journey. It can be a challenging path through the complex maze of healthcare systems at a time of physical and emotional change for both the person diagnosed and those around them.

Recognising the need to understand the experiences of the patients and carers at the heart of cancer services, the WA Health Department recently partnered with Health Consumers’ Council (HCC) to gather insights to help inform the future of cancer care in WA. A diverse group of patients, consumers and carers generously shared their experiences, challenges and aspirations with us, and we were guided by the invaluable support and expert advice of health consumer advocate Dr Susannah Morris.

The open and candid conversation about their personal experiences with cancer services reflected on the parts of their care that were difficult, and those that were handled well, giving insights into the emotional

and practical needs of patients navigating cancer treatment.

Not just the location One of the critical areas of discussion that we heard about from many was the importance of the location, and configuration, of cancer care. While different locations were preferable depending on patient needs, what we heard was that wherever the location was, care needed to be centred around the person and their needs.

This aspect of care is not only about geographical convenience but also about the comfort and peace of mind patients have when they know support is within reach. The need for flexibility and accessibility in care locations was a recurring theme.

Above and beyond the technicalities of treatment, what stood out in the consultations was the need for better care navigation and a more consistent and early linking of consumers and carers with all pertinent support services, to be treated as whole people not just a disease.

Better communication, flexible appointment times, a more seamless and coordinated care experience, care navigators and navigation tools were among the top suggestions from participants.

As the consultations revealed, there is an essential need to ensure that cancer services in WA are aligned with the second goal of the WA Cancer Plan 2020-2025 to ensure that consumers have the best experience of care. This implies that optimal care should be person-centred, safe, high-quality, multidisciplinary, supportive and well-coordinated.

People were also concerned that they ‘lived well’ with and beyond their diagnosis, in keeping with priority three of the plan. The consultations highlighted that while much has been achieved, there are still gaps that need bridging.

ED: For a full copy of the report, email engagement@hconc.org.au Tania Harris is the HCC’s Engagement Manager, Aboriginal and Disability Engagement Lead.

A closer look at eye cancer Edith Cowan University research is a step closer to understanding why uveal melanoma – the deadliest form of eye cancer – has a high rate of metastasis.

The rare cancer has an incidence of 7.6 per million adults in Australia and represents around 5% of all melanomas.

Patients with uveal melanoma have a 50% chance of the disease metastasising from the eye, commonly to the liver, even after successful treatment of the tumours within the eye.

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Metastases of uveal melanoma could develop up to 20 years after the primary tumour treatment, and the median survival in patients after a diagnosis of metastases is 5 -18 months.

ECU Vice Chancellor’s Research Fellow Dr Vivian Chua said that after diagnosis of the disease in the liver, patient survival was often short due to the lack of effective treatment options.

including skin melanoma.

Researchers were trying to identify how and why uveal melanoma metastasised to the liver.

Dr Chua’s recent research has focused on alterations in the BRCA1-associated protein 1 gene, which modulates the characteristics of cancer cells, particularly uveal melanoma.

Metastatic tumours responded poorly to many treatments that were effective in other cancers AUGUST 2024 | 33

Risks are flying high With many West Australians escaping winter for warmer climates, it is a good time to remind patients about travel-related venous thromboembolism, writes Professor Ross Baker from the Perth Blood Institute.

Forms of deep vein thrombosis (DVT) and pulmonary embolism (PE) are one of the most notable and alarming complications associated with air travel.

I encourage GPs to reinforce the risks associated with VTE and flying and assess additional factors that increase a patient’s probability of developing travel-related VTE while on long-haul flights.

While VTE is relatively well known in the community, the business of wrangling suitcases, entertaining children, watching movies and generally getting through a longhaul flight, tend to put it to the background of traveller’s minds.

The risk of VTE is 1.2%, if relying on ultrasound testing research studies, although only 0.05% when studies have considered solely symptomatic DVTs. However, it is difficult to determine the precise cause of a DVT or PE as there can be a variety of risk factors.

For patients with a history of DVT considering travel, a significant concern should be flight duration.

The WHO’s WRIGHT project in 2007 suggested that the absolute risk of VTE on a flight 4+ hours long was 1:6000. More recent literature concurs with this data, proposing that flights longer than four hours appear to be the benchmark for increasing VTE risk.

One study also proposed a 34 | AUGUST 2024

threefold elevated VTE risk was associated with a cumulative travel time of more than 12 hours within a 4-week period. With anything from a 4-5-hour flight between Perth and Brisbane to a non-stop 18-hour flight from Perth to London, it is recommended that patients with a history of DVT discuss their health status with their GP before flying.

Observational studies also found that there is an absolute risk for

symptomatic VTE within four weeks after flights longer than four hours. Flights lasting less than four hours, the risk of VTE was two times higher compared with non-travellers, and journeys longer than 12 hours, the risk increased to three times higher. Also, the risk of severe PE immediately after a flight increases from zero in flights less than three hours to 4.8/1 million persons in flights over 12-hours.

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Sitting for large periods of time during a flight – coined ‘economy class syndrome’ – can also be mitigated by encouraging travellers to regularly get up and move around during the flight.

If someone has recently been diagnosed with a VTE or a blood clot, they should speak with their GP to determine if air travel will be safe.

The literature suggests that VTE patients taking anticoagulants can safely fly as long as they maintain their medication regime and should ensure they have a sufficient supply

with them (not in checked baggage) throughout the journey.

Sitting for large periods of time during a flight – coined ‘economy class syndrome’ – can also be mitigated by encouraging travellers to regularly get up and move around during the flight. While seated, to stretch your calf muscles, frequently flex and rotate your ankles and knee flexion is very useful. Other proposed exercises include shrugging and moving your shoulders and nodding and tilting your head.

Additional recommendations include staying hydrated, avoiding constrictive clothing, particularly around the legs, and in some circumstances the use of properly fitted graduated compression stockings. For travellers with increased risk of thrombosis, GPs might suggest a single dose of lowmolecular-weight heparin (LMWH) before departure.

In regard to other pharmacological prophylaxis, research has found that platelet anti-aggregant and aspirin are not recommended.

However, there is no evidence showing that direct oral

anticoagulants (DOACs) cannot be used as prophylaxis for travelrelated VTE. In addition to immobility, there are several other factors which may contribute to increased VTE risk during flights. These can include: • Hypobaric hypoxia • Low humidity/dehydration • Thrombophilia/Factor V Leiden • Pregnancy risks • Cancer sufferers • Post-operative risks GPs can address this list when assessing a patient’s suitability for long-haul flights and make suggestions to significantly reduce the risk.

ED: Professor Baker is associated with Thrombosis Australia, an initiative aiming to reduce the incidence of blood clots in Australia through education. As he advises, the risk of VTE can remain weeks after returning from a long-haul flight, so it is important to act on the signs and symptoms associated with DVT. More information is on the Thrombosis Australia website www.pbi.org.au/ thrombosis-australia.

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Dr Joe Kosterich | Clinical Editor

Studying human capability As you read this, the Olympics will be well under way.

Every four years many of us become interested in and experts on sports that we generally do not care about.

“The more athletes experience and push through pain in training, the less emotionally triggering the pain becomes” – Jim Doorley, sports psychologist

The ancient Olympics, first held in 776BC in Greece, are claimed to have been held to bring people together even in time of war. Necessarily it was also a spectacle. The Romans also understood spectacle and the notion of giving the masses bread and circus hails from those times To me, it is fascinating to see what the human body can achieve. Why is it that some people can jump higher and others run faster? Why is it that athletes can continue in the face of pain or discomfort that would cause others to stop and even seek medication?

Genetics may play a role as human beings have different innate talents.

But talent without effort will not achieve much. In turn we could ask why are some people so dedicated to their tasks? Olympic sports are typically not big-paying ones so it’s not money. Until recently athletes had to be amateur and were not allowed payment.

A recent piece on Medscape asked – What can Olympians teach the rest of us about pain?

“You could say elite athletes have a friendlier relationship with pain than the average person,” said Jim Doorley, PhD, a sports psychologist with the US Olympic and Paralympic Committee. “The more athletes experience and push through pain in training, the less emotionally triggering the pain becomes”.

Could we apply some of these ideas in how we manage pain?

This month’s theme is cancer care. A question that arises is why do some people go into remission? It is put down to luck. But what if there is something we could learn? We are remarkably incurious about this phenomenon.

In 1971, then President Nixon declared a ‘war’ on cancer with the aim of eradication by 1976. Detection, treatments and survival have improved.

Rates have also increased with projections to increase further.

Medicine is about studying disease and it has served us well. Maybe it is time to also study those who are healthy and do well – not just those who don’t.

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The hidden link: How obesity fuels the fire of cancer

By Dr Imran Badshah, Endocrinologist, Nedlands Despite the established link between obesity and cancer, the molecular mechanisms remain under investigation.

Obesity is characterised by excess fat storage and adipocyte mass, leading to local changes (chronic low-grade inflammation, altered adipokine/cytokine secretion) and systemic disorders (insulin imbalance, IGF-I axis abnormalities, changes in hormone biosynthesis, and inflammation-related mediators like IL-1β, TNF-α, and IL-6).

These factors can impact cancer cell survival and proliferation, influencing both the tumour phenotype and its microenvironment. Key mechanisms include: Inflammation: Chronic inflammation in adipose tissue promotes tumour initiation, growth, angiogenesis and metastasis leading to poorer outcomes and reduced therapeutic response.

Obesity-induced adipocyte hyperplasia/hypertrophy and death trigger the release of inflammatory molecules and macrophage infiltration creating a pro-inflammatory state sustained by a paracrine loop involving macrophages and adipocytes Insulin/IGF-1 Axis: Obesity, particularly visceral fat, contributes to insulin resistance, hyperinsulinemia and hyperglycaemia. Insulin and IGF-1 promote carcinogenesis through direct and indirect pathways including the Ras/Raf/ERK and PI3K/Akt/mTOR signalling cascades.

Adipokines: Adiponectin and leptin, key adipokines, play significant roles in obesity-related tumorigenesis. Low adiponectin levels are linked to obesity and insulin resistance, while high leptin levels correlate with poor cancer prognosis.

Various cancers Obesity significantly increases colorectal (CRC) risk. A metaanalysis of 12,837 CRC cases showed that abdominal obesity, measured by waist circumference 38 | AUGUST 2024

Key messages Obesity is linked to increased risk and mortality in various cancers, including colorectal, breast, and gynaecological cancers Adipose tissue, through its chronic inflammation, drives the obesity-cancer connection Understanding the mechanisms connecting obesity and cancer could lead to novel biomarkers and therapeutic interventions.

(WC) and waist-to-hip ratio (WHR), raises CRC risk equally across genders and regions. Greater WC and WHR were linked to higher risks for total colorectal, colon and rectal cancers.

Obese CRC patients also face higher all-cause and cancer-specific mortality, disease recurrence, and worse disease-free survival. Even moderate weight gain increases CRC risk, especially in men. High BMI in individuals under 30 is also associated with higher CRC risk.

Elevated leptin levels in obese individuals further connect obesity to CRC. Obesity significantly increases the incidence and mortality of breast cancer, especially in postmenopausal women. Studies show that overweight and obese women are more likely to develop hormone receptor-positive and HER2-negative breast cancer, as well as more aggressive types like triple-negative breast cancer (TNBC).

A meta-analysis of 12 studies with 22,728,674 women reported a 2% increase in breast cancer risk for every 5kg/m² rise in BMI among postmenopausal women, whereas a higher BMI might be protective for premenopausal women.

Obesity increases the risk of cervical cancer, as shown in a study of over 900,000 women, where obese women had the highest five-year cumulative risk of cancer. Maintaining a healthy

BMI and regular physical activity can reduce cervical cancer risk.

A Korean study found that class II obesity significantly increased cervical cancer risk, regardless of menopausal status.

Studies show that visceral adiposity, rather than BMI alone, increases the risk of ovarian cancer.

A 2019 study involving 6,681,795 participants found that higher BMI, especially from early adulthood, raises ovarian cancer risk.

Endometrial cancer is strongly associated with obesity. A metaanalysis of over 22,300 cases found that higher BMI significantly increases endometrial cancer risk.

This association is independent of factors like diabetes, hormone therapy and reproductive history.

Assessment and prevention Traditional BMI measurement is insufficient to distinguish between subcutaneous adipose tissue (SAT) and visceral adipose tissue (VAT), which have different implications for cancer. VAT is more metabolically active, produces more adipokines, and is closely associated with internal organs, making it more relevant for cancer development.

Advanced imaging techniques like CT and MRI are recommended for assessing VAT in cancer patients.

Leptin (a 16-kDa hormone) regulates food intake, energy expenditure, immune response and reproductive processes. In cancer, leptin binds to its receptor (ObR), part of the class 1 cytokine receptor family, influencing cell proliferation, metastasis, angiogenesis, and chemoresistance. Leptin is wellknown for its significant role in the biology of various cancers, although its function in lung cancer remains debated and is still being studied.

High-grade breast cancer has been shown to exhibit overexpression of leptin and its receptor (ObR), which is associated with poor prognosis and increased risk of distant metastasis. continued on Page 40 MEDICAL FORUM | CANCER CARE

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Clearing the fog: The hidden challenge in chemotherapy treatment

By Dr Virginie Lam, Research Fellow, Curtin University Whilst significant advancements in clinical oncology that have improved long-term survival rates in cancer patients, the public health impact of cancer survivorship remains an area of unmet need.

One of the most debilitating consequences of cancer treatment is chemotherapy-induced cognitive impairment, often referred to as ‘chemobrain’ or ‘foggy brain syndrome’. This term describes the neurocognitive sequalae experienced by cancer patients during and following chemotherapy due to the substantial off-target effects of certain chemotherapy regimens on the central nervous system.

Globally, about 60% of cancer patients undergo chemotherapy.

A modelling study published in the Lancet Oncology projects a 53% increase in the utilisation of first-line chemotherapy treatments by 2040, attributed to escalating cancer burden.

Breast cancer patients and survivors have a high incidence of chemobrain, with two-thirds presenting with clinically significant cognitive impairment following chemotherapy, reporting symptoms such as memory loss, difficulty concentrating and challenges in completing daily tasks. These cognitive impairments make it difficult for individuals to care for their families, return to work, study, or maintain a social life.

In breast cancer management, the utilisation of chemotherapy varies widely, ranging from 10-90% of cases depending on the stage and subtype of cancer. Typically, chemotherapy is employed in cases of advanced breast cancer, aggressive subtypes such as triplenegative breast cancer, or when the cancer has metastasised to lymph nodes or other organs.

Approximately 50% of individuals experience long-lasting clinically significant cognitive impairment that can persist for months and up to 20 years after the cessation

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Key messages Chemotherapy can lead to clinically significant cognitive impairments known as ‘chemobrain’, affecting memory, concentration, and daily functioning Chemobrain is particularly prevalent in breast cancer patients, with about two-thirds experiencing symptoms following chemotherapy for up to 20 years after cessation of treatment Despite its prevalence, the pathophysiology of chemobrain is poorly understood, with no approved preventive or therapeutic strategies. Further research is needed.

of chemotherapy. Despite its prevalence and significant burden on breast cancer patients and survivors’ quality of life, the pathophysiology of chemobrain remains poorly understood, and there are no approved therapies for its prevention or treatment.

Clinical follow-up neuroimaging studies in breast cancer patients who have undergone chemotherapy have revealed functional and structural changes in brain regions crucial for learning and memory.

These alterations include shifts in resting metabolism, hippocampal volume, and abnormalities in white matter microstructure.

Despite an increasing number of preclinical studies and clinical trials exploring the benefits of various lifestyle modifications, exercise interventions, cognitive rehabilitation through brain training/stimulation, and drug repurposing to ameliorate the condition, there are currently no recommended therapeutic treatment strategies to prevent chemobrain or improve cognitive outcomes in affected patients.

Moreover, the severity of chemobrain is likely underestimated due to lack of sensitivity and standardisation in neuropsychological assessments for cancer patients. There is a

pressing need for novel approaches to comprehensively understand its pathophysiology and develop effective treatments for this primary comorbidity encountered by cancer patients and survivors.

An increasing body of preclinical animal model studies indicates that common first-line chemotherapies possess neurotoxic properties capable of inducing cognitive impairment.

Proposed mechanisms underlying chemotherapy-induced cognitive impairment are diverse and include neuroinflammation, increased oxidative stress, impaired myelination, neurodegeneration and anti-angiogenic effects, the latter leading to compromised microvascular blood flow.

Additionally, chemotherapy-induced disruptions to the blood-brain barrier may permit chemotherapeutic agents to enter the brain parenchyma and directly instigate cytotoxic effects. Intriguingly, the incidence of chemobrain is nearly doubled in individuals carrying the APOE4 gene, recognised for its association with neurovascular dysfunction and identified as the strongest genetic risk factor for Alzheimer’s disease, and thus may be a primary underlying causative mechanism of chemobrain.

Our research group is currently testing potential treatment solutions using novel neuroprotective compounds developed in our laboratory, utilising preclinical models of chemobrain. These compounds are ideal therapeutics for treating the multi-faceted nature of the syndrome due to their pleiotropic properties.

While previous efforts have predominately focused on treating chemobrain post-chemotherapy, our strategy aims to prevent its onset or mitigate its severity pre-emptively. By better understanding the underlying mechanisms of chemobrain, we hope to identify therapeutic candidates for clinical translation.

Author competing interest – nil

AUGUST 2024 | 39

Save the breast!

By Mr Ran Li, Oncoplastic Breast Surgeon, Nedlands Breast cancer is the most common cancer in Australian women and its incidence continues to increase.

Fortunately, the majority are diagnosed at an early stage and surgery remains the mainstay of treatment – usually with curative intent. An important discussion for the patient and surgeon is whether to undertake breast conservation surgery or mastectomy, with or without reconstruction.

Traditionally, breast surgeons have counselled patients that breast conservation surgery (with radiotherapy) is non-inferior to mastectomy in terms of overall survival, backed by large studies with long-term outcomes. However, recent evidence from several meta-analyses have shown that breast conservation surgery and radiotherapy may in fact be superior to mastectomy for both overall survival and cancer specific survival.

The reason why this is the case remains unclear. Theories include the possible abscopal effect of radiotherapy, or perhaps that after mastectomy, patients no longer have routine surveillance mammograms.

In addition, research looking at quality of life has repeatedly shown that patient satisfaction in terms of cosmesis, psychosocial and sexual wellbeing are better after breast conservation surgery compared to mastectomy, even with reconstruction.

Studies have also shown that oncoplastic surgeries are safe and do not compromise long-term oncological outcomes compared to traditional breast conservation surgery. Mastectomy and breast conservation surgery can no longer be considered equivalent for longterm quality of life or oncological outcomes and patients should be informed of this as a part of the initial surgical discussion.

Modern oncoplastic surgical techniques allows for breast conservation surgery to be performed, with excellent cosmetic outcomes, for tumours that traditionally would have required a mastectomy. Breast surgery has come a long way since the days of the Halsted mastectomy – a procedure removing the whole breast, pectoralis muscle and lymph nodes, resulting in devastating morbidity.

In the 1980s, breast conservation surgery was widely adopted for cancers with a favourable tumour to breast volume ratio. Since the early 2000s, oncoplastic techniques have been adopted by many breast surgeons worldwide, resulting in better long-term cosmesis and cancer outcomes for patients.

In order to achieve a good cosmetic outcome for larger breast cancers, modern oncoplastic techniques need to be utilised.

Many oncoplastic-trained breast surgeons now offer Level II oncoplastic breast conservation procedures, meaning removal of more than 20% of the breast volume, for tumours that otherwise would require mastectomy.

Level II oncoplastic surgeries are categorised into two main types – volume replacement or volume displacement procedures.

In volume replacement surgery, the defect left after removing the cancer with an adequate margin needs to be filled with a flap of non-breast fatty tissue to avoid asymmetry (Fig 1). These volume

How obesity fuels the fire of cancer continued from Page 38 A documented positive correlation exists between circulating leptin levels and the risk of endometrial cancer. Some studies have reported higher levels of leptin and its receptor (Ob/ObR) in endometrial cancer tissues compared to normal endometrial tissues.

Future therapeutics In addition to its vital physiological functions, leptin plays a significant role in tumour development and progression. Consequently, there is an increasing need to design new therapies that can disrupt 40 | AUGUST 2024

leptin signalling in cancer. Over the past few decades, various leptin-related agonists and antagonists have been developed.

Among these, leptin mutants, leptin receptor antagonists, and neutralising antibodies have shown considerable promise.

A small peptide based on the wild-type sequence of the leptin binding site I (LDFI), synthesised

by Andò et al. in 2015, competes with leptin to block its receptor signalling, showing significant results in various cancers, including breast cancer, seminoma and glioblastoma.

Inhibition of leptin signalling correlates with decreased cell proliferation and tumour growth, as evidenced by xenograft experiments. Another ObR antagonist, Aca1, reverses the mitogenic and angiogenic effects in glioma cell lines on endothelial cells.

Specific anti-leptin-receptor monoclonal antibodies (anti-LR mAbs) may be more efficient due to their high molecular mass and longer circulation half-life.

– References available on request Author competing interests – nil

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Pre op

achieve a smaller breast size but with a cosmetically pleasing shape and contour, which is essentially a breast reduction type procedure (Fig 2); usually the contralateral side can be reduced to match the cancer side at the same time.

These volume displacement procedures are called therapeutic mammoplasties.

Pre op

Post op

Post op

Figure 1. Volume replacement breast conservation surgery utilising a perforator flap. The red shaded area represents the volume of tissue needed to be excised to remove the multifocal cancers for this patient. The post op photo is six months after her initial surgery.

Figure 2. Left therapeutic mammoplasty (and axillary clearance) with right symmetrising reduction mammoplasty to remove a 4 cm left sided invasive ductal carcinoma.

replacement procedures are usually in the form of a perforator flap partial breast reconstruction, where a wedge of fatty tissue from the lateral chest wall or tissue under the breast is mobilised, kept on its

blood supply and rotated to fill in the tumour cavity.

For volume displacement surgery, the entire breast needs to be remodelled and reduced in size to

Oncoplastic breast surgery is pushing the possibilities of breast conservation surgery to allow many more patients to avoid mastectomy and still have acceptable cosmesis.

Given the emerging evidence that breast conservation surgery is likely superior to mastectomy for long-term cancer survival, not to mention quality of life, it is crucial that surgeons are counselling patients with breast cancer appropriately.

It is also important that patients have access to oncoplastic surgeons with the appropriate subspecialty training, so that they are aware of their full range of surgical options.

Author competing interests – nil

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Hollywood Consulting Centre Suite 413, 91 Monash Ave, Nedlands WA 6009 Phone: 9386 6200 HL: stpnonosh

AUGUST 2024 | 41

Changes in colorectal cancer incidence rates in young adults

By Dr Stephanie Chetrit, Colorectal Surgeon, Mt Lawley Colorectal cancer (CRC) is predominantly a disease of older adults, but a concerning trend is the rising incidence among young patients under 50, while the incidence is decreasing in older adults primarily due to colonoscopy guidelines and pick up. Understanding the incidence, staging, and aetiology of colorectal cancer in the younger demographic is crucial for effective diagnosis, treatment, and prevention.

Over the past few decades, the incidence of colorectal cancer in young patients has seen a notable increase. Recent statistics reveal a 1-2% annual rise in CRC cases among individuals aged 20-49.

This demographic now accounts for about 1 in 10 colon cancers in Australia. Our own database in the Western Australian St John of God Health Care group would suggest the same and more of an increase in the past three years with an average of 13.7% of our cohort being less than 50 at the time of diagnosis.

Several factors contribute to this upward trend, and it is still not fully understood. Increased awareness and improved diagnostic techniques are crucial for earlier and more frequent detection.

However, lifestyle factors such as sedentary behaviour, poor diet, obesity, and smoking are also significant contributors. Studies suggest that the rising prevalence of these risk factors among young people parallels the increased incidence of CRC in this group.

Unfortunately, diagnostic protocols are targeted to older patients with age becoming a bias. Being younger means not being routinely screened for CRC, patients have delayed access to investigations such as colonoscopy often with multiple visits to general practitioners and specialists.

As expected, delay in diagnosis means more advanced stage at diagnosis. There is some evidence that younger patients often 42 | AUGUST 2024

Key messages The rising incidence of colorectal cancer in young patients is a pressing public health concern Colorectal cancer is already the second most common cancer and the second most common cause of cancer deaths in Australia Younger patients require higher level of scrutiny and more careful and timelier follow-up of symptoms.

present with stage III and IV cancer with more aggressive disease characteristics.

Stage IV colorectal cancer in young individuals involves distant metastasis to organs such as the liver or lungs. Young patients often face a more aggressive disease course with a higher likelihood of multiple metastatic sites. Treatment usually involves a combination of surgery, chemotherapy, targeted therapy, and sometimes immunotherapy.

Despite the aggressive nature of the disease, younger patients often respond better to treatment, showing longer survival times compared to older patients, but the overall five-year survival rate remains low at around 14%.

The following recurring symptoms should be immediate red flags, with increased risks with more than one symptom: abdominal pain, rectal bleeding, change in bowel habit, usually diarrhoea and deficiency anaemia.

However, some of these symptoms can be attributed to irritable bowel syndrome (IBS), which is quite prevalent in young adults making it more challenging to identify those patients who need to proceed to colonoscopy. It is certainly useful for patients to be familiar with the importance of those symptoms.

The incidence of rectal cancer incidence also seems to be on the rise and a rectal examination will help identify a low rectal mass.

Bowel Cancer Australia recommends Faecal Occult Blood Test every two years from the age of 45 in asymptomatic patients. From July 1, the National Bowel Cancer Screening Program (NBCSP) has also made that age group eligible for testing. The test can be offered to ‘concerned’ or ‘concerning’ patients aged 40-44.

Ultimately, the rise in colorectal cancer in young patients means a thorough history taking in particular of the personal and family history of cancer and polyps will help determine the risk of each patient, hence guiding the referral for investigations.

Genetic counselling and testing of young patients with colorectal cancer can further identify at risk patients and family members.

Moreover, there is good evidence (level 1) that starting low dose aspirin in those high risks patients can reduce incidence and death from CRC. Young adults’ colorectal cancer diagnosis also brings on new challenges such as oncofertility and discussing fertility status and options for parenthood after cancer is important.

The rising incidence of colorectal cancer in young patients is a pressing public health concern.

CRC is already the second most common cancer and the second most common cause of cancer deaths in Australia. The NHMR has clear recommendations for prevention, early detection and management of CRC. Younger patients require a higher level of scrutiny and careful and timely follow-up of symptoms.

– References available on request Author competing interests – nil

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Advances in surgical management of thymic tumours – robotic thymectomy

By Dr Pragnesh Joshi, Cardiothoracic Surgeon, Nedlands Thymic cancers are exceedingly rare, with an incidence of one to two cases per 100,000 personyears, with exceptionally diverse presentations. True incidence is unknown.

With increasing use of CT of chest for lung cancer screening, cardiac screening and preoperative evaluations, we have experienced an increase in diagnosis of thymic tumours. Thymic epithelial tumours make up 35% of all anterior mediastinal mass while lymphoma and germ cell tumours make up the other most common pathologies.

About a third of the patients with thymoma can be associated with myasthenia gravis. One of the biggest challenges of incidentally diagnosed thymic mass is its management.

The following tests are most useful in making diagnosis of thymic tumours in descending order: 1. CT chest with contrast 2. MRI of chest 3. PET scan 4. Biopsy Radiology is the mainstay of the diagnosis of thymic tumours. CT scan is most commonly used radiological test followed by MRI. Contrast CT scan is highly desirable to assess the relationship of thymic tumour with great vessels, pericardium, phrenic nerves and heart. CT scan is quite reliable in

with morbidities of sternal split, bleeding, pain, infection, scarring and prolonged hospital stay and recovery.

Many of the disadvantages of sternotomy are overcome by VATS and Robotic approaches. VATS approach has been limited to those who expertise in VATS surgery.

Only few surgeons carry out VATS thymectomy routinely in Australia.

Minimally invasive approach is ideal for smaller thymic tumours (less than 5cm). making diagnosis of thymoma with high probability, based on tissue characteristics, location, shape and invasion.

MRI is used to distinguish solid thymic tumour from thymic cyst which are likely benign. Other use of MRI is to assess invasion of mediastinal structure by thymic tumour in particular thymic carcinoma.

Pre-treatment biopsy for diagnosis is not always necessary as long as robust diagnosis of thymic tumour can be made with radiology and the tumour is surgically resectable.

Biopsy is considered under following circumstances: 1. High probability of other diagnosis e.g. lymphoma or germ cell tumours 2. Patient prefers for surveillance rather than excision – biopsy to rule out cancer.

Thymoma is the commonest pathology of thymic epithelial tumours

One of the side effects of large biopsy is breaching of capsule, in case of thymoma. Thymoma are notorious for causing drop metastasis if the spillage occurs after biopsy.

Contrast enhances CT scan is one of the most reliable test for diagnosis and role of biopsy is debatable

The surgical approaches for thymectomy are sternotomy, videoassisted thoracoscopic surgery or robotic thymectomy.

Best treatment for thymoma is surgical excision with excellent long-term outcomes. Robotic thymectomy has advantages over VATS thymectomy and sternotomy.

Sternotomy has been a standard approach for many years for most surgeons. It provides great exposure and allows for simple as well as complex thymectomy for thymic tumours. But sternotomy approach is also associated

Key messages

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Robotic thymectomy Robotic thoracic surgery has been available in Australia for more than a decade, but it was first introduced to Perth in July 2023.

It is a port access technology for keyhole surgery. Robotic arms are introduced in the chest cavity by multiple (usually three) ports.

Robotic arms are controlled by the robotic thoracic surgeon who is not scrubbed at the operating table but is present in operating theatre working on the robotic console.

Multiple studies have consistently shown that robotic thymectomy has many advantages.

One of the biggest is 3D vision allowing surgeons to visualise intrathoracic structures as the surgeon would see it in open cases.

Robotic technology comes with high definition camera technology and significant magnification of structures which allows for better visualisation of anatomy with improved precision to carry out surgical steps. The surgeon has control of all the instruments rather than assistant surgeon. Surgery generally takes around 60-80 minutes and hospital stay is usually less than two days.

Author competing interests – the author was the first in WA to introduce robotic thymectomy

AUGUST 2024 | 43

The Western Australian Gynaecologic Cancer Service (WAGCS) Survivorship Clinic

By Dr Chloe Ayres, Gynaecologic Oncologist, Perth Cancer survivorship refers to a person living with cancer, from the time of diagnosis and primary treatment to the longerterm effects of the cancer and treatment itself, through to end of life. Historically it was a term used from completion of active cancer treatment, but there is now a shift to provide survivorship care from the point of diagnosis to improve the patient experience and outcomes.

care needs which conventional oncology services cannot fulfil.

Cancer survivors require greater support in areas of healthcare that focus on their quality of life, their experience of the care process, functional outcomes, and the ongoing management of comorbid conditions.

An ageing population, earlier detection and diagnosis, and improvements in cancer treatment have all resulted in greater survival rates and as a result the Australian healthcare system continues to treat a growing population of long-term cancer survivors.

Cancer can have a lasting impact including: • Ongoing physical and emotional side effects from treatment that impact on wellness, including fatigue, changes in thinking and memory, and mood • Fear of the cancer coming back or progressing • Practical concerns around finances and return to work.

Over one million Australians are now living with or beyond their cancer diagnosis. Two thirds of people surviving a cancer diagnosis report having ongoing unmet health

The Cancer Australia Principles of Cancer Survivorship provides a national framework to guide policy, planning and health system responses. These principles

recommend that people affected by cancer receive holistic patientcentred care which is coordinated and integrated across treatment modalities, providers and health settings, including the public sector so that care is delivered in a logical, connected and timely manner for optimal continuity and to meet individual needs of the people affected by cancer.

The Australian Institute of Health and Welfare reported that there were more than 21,000 individuals living with gynaecological cancer in 2016.

Aboriginal women are 1.7 times more likely than non-Aboriginal women to be diagnosed with gynaecological cancer and are particularly overrepresented in cervical cancer.

Cancer modelling studies have predicted a 54% increase in the number of cancers in women and a decrease in mortality rates, which has meant an increasing number of survivors. More than half of all

WAGCS Survivorship Team

44 | AUGUST 2024

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Key messages Cancer patients have long lasting complex cancer survivorship needs Multidisciplinary tumour stream specific clinics are needed to address survivorship issues and the patient experience and outcomes Shared survivorship care with GPs plays an integral part.

young, having had curative intent but multimodal treatment (surgery, radiation and chemotherapy) and have high unmet supportive care needs including those affecting bowel and bladder function, sexual health (loss of sexual function or dysfunction, sex and intimacy issues), surgical menopause, loss of fertility, chronic pain and lymphoedema.

Referrals will initially be from existing public patients, with the ultimate goal to have equity of access for all as the service grows.

There currently is no comprehensive gynaecologic cancer survivorship clinic in Australia. The Western Australian Gynaecological Cancer Service (WAGCS) has identified a gap in the provision of coordinated service delivery and implemented the first such clinic in Australia in July this year.

The service will be led by a multidisciplinary team including gynae-oncologist Associate Professor Emma Allanson and Professor Paul Cohen, specialist nurse, physiotherapist, clinical psychologist, dietician, palliative care and liaison GP. The RACGP has just recently released a new college cancer survivorship shared care position statement in June that highlights the role of GPs in providing holistic and comprehensive care coordination.

Cervix and vulva cancer patients and select endometrial cancer patients will form the main group of survivors. These patients are mostly

The WAGCS survivorship clinic is a half-day weekly clinic. It commences with a multidisciplinary case conference of expected patients. The

gynaecological cancer survivors experience long-term physical and psychological side effects from their diagnosis and treatment.

Surgery for Heel Pain Heel pain is a frequent problem that presents to the general practitioner. Plantar fasciitis is the most common cause of under the heel pain. Most patients will improve with non-operative treatment but not all.

Surgery is a very effective form of treatment for this condition in patients with long standing refractory symptoms.

Before being considered for surgery patients should undergo at least six months of non-operative treatment that includes the following (in the appropriate order): • Rest, avoidance of activity • NSAIDs, stretching exercise program • Orthotics: off the shelf or custom • Cortisone injection (one only) • Shockwave therapy

Plantar fascia origin

Surgery can be open or endoscopic.

The principle part of the procedure is release of the plantar fascia near its origin on the heel. Historically only the medial half was released but recent literature supports more complete release.

patients are informed that the first visit can takes at least three hours to see all clinicians required to meet their survivorship needs.

A survivorship care plan is prepared for patients (and their primary care provider) and routine oncology follow-up is incorporated into their survivorship visits. The development of individual survivorship plans for patients is based on Patient Reported Outcome and Experience Measures (PROMs/PREMs), which measure physical, social, emotional, sexual and functional wellbeing.

The ultimate goal is to establish collaborative partnerships between patients and health professionals including GPs to empower cancer survivors to self-manage their health and well-being.

Author competing interests – nil

By Mr Peter Ammon Foot Ankle & Knee Surgery

Open surgery is performed through a 3cm incision in the proximal arch and allows not just plantar fascia release but also decompression of the tarsal tunnel and Baxters nerve which is often implicated in heel pain.

Endoscopic plantar fascia release is indicated for those without nerve compression symptoms and is done through a much smaller incision using a camera assisted cutting device much like a carpal tunnel release.

Both open and endoscopic releases are performed as day cases and require approximately two weeks on crutches. Recovery is slightly quicker for endoscopic patients as you would expect. Patients can expect an 8090% chance of a good result from surgery. Complications are rare.

St John of God Medical Centre Suite 10, 100 Murdoch Drive, Murdoch WA 6150 Telephone: (08) 6332 6300 Facsimile: (08) 6332 6301 www.murdochorthopaedic.com.au Murdoch Orthopaedic Clinic Pty Ltd ACN 064 146 774 ABN 23 070 745 210

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AUGUST 2024 | 45

Study to test efficacy of ‘hearables’ GPs are being encouraged to refer suitable patients to a Perth study that looks at the benefits of personal hearing devices known as ‘hearables’ – and will give participants one for free.

Two WA research bodies – Ear Science Institute Australia and the University of WA – are seeking participants to determine whether improving hearing using personal amplification devices (hearables), together with a behaviour activation program, could improve mood and social participation.

The research team needs people aged 65 years or older who are experiencing mild to moderate hearing loss that is affecting their daily lives and contributing to low moods.

The trial will take place over sixmonths and all participants at some point during the trial will be gifted a hearable device worth $500.

Hearables are like wireless ear buds that fit inside the ear and amplify sounds through a smartphone app.

They are available over the counter and popular with people who have mild hearing loss and want to improve their hearing in certain situations.

The study is being led by Dr Dona Jayakody from Ear Science and Dr Andrew Ford from Sir Charles Gairdner Hospital and UWA. Dr Jayakody said participants would be divided into four groups, and ultimately the researchers wanted to determine which group would benefit more from the help being offered.

“We want to know if fitting a hearable device is enough to improve someone’s low mood, or do they need more help to get back to where they were before any hearing loss and re-engage in activities they may have retreated from,” she said.

Due to loss of hearing, some people give up hobbies or activities they used to enjoy, or they may not contribute to social conversations as much because of feelings of embarrassment and frustration.

46 | AUGUST 2024

Dr Jayakody with study participant Michèle Drouart

Dr Ford added that behavioural activation was a relatively simple psychological intervention that encouraged people to become more engaged in activities and social conversations again, with the aim of improving mental wellbeing.

“Our behavioural activation program focuses on reducing the social isolation and mental distress that is commonly associated with hearing loss,” he said.

Michèle Drouart, from Mount Claremont, is a current study participant and says worrying thoughts about diminishing brain function that came with even early mild hearing loss had begun to eat away at her.

“The hearables were a good start for working on my hearing difficulties, and they were especially useful as something to fall back on while I sorted out my hearing loss needs, and it was a comfort to know I had them,” she said.

“The other, and perhaps best part of the study for me, has been the help I received with how to cope with the effects of hearing loss, even in the early stages.

“While I wasn’t depressed, I had been experiencing anxiety, some of which was directly related to my

hearing loss. The coping strategies I learnt from the behavioural part of the study have enabled me to manage that. This study can really help people in the early stages of hearing loss.”

Participants needed to meet the following criteria: • aged 65 and older • experiencing symptoms of low mood • not currently using a hearing aid or hearable device • competent in written and spoken English • willing to provide consent for participation • experiencing mild-to-moderate hearing loss that was affecting daily function and quality of life.

The study has been given a grant of $600,000 from the National Health and Medical Research Council.

Anyone wanting to register their interest can contact research team coordinators Matthew Zimmermann on 0476 987 837 or Hema Patel on 0484 068 188.

For more details go to www.earscience.org.au/research/ brain-hearing/hearables-andbehaviour-study/

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Meeting the global challenge of neurological disorders

By Dr Jan Ho, consultant neurologist, Perron Institute In a recent Lancet Neurology article, the Global Burden of Disease Nervous System Disorders Collaborators reviewed the global burden of 37 nervous system diseases (in 2021) and estimated that 3.4 billion people (43% of the total population) suffered from a nervous system condition.

The accompanying morbidity and mortality come at immense economic and personal cost. The 37 conditions analysed caused 443 million DALYs and were the top-ranked contributors to global DALYs, with cardiovascular disease coming second.

The top three nervous system conditions were headaches (migraines and tension type, 3.17 billion), diabetic neuropathy (206 million) and stroke (93.8 million).

There are differences in the disease burdens of these conditions, however, the ability to accurately diagnose, manage, on-refer and educate patients in a timely way are vital in reducing disease burden and disability.

Understanding migraine has advanced, in particular, the discovery of the role of calcitonin gene-related peptide (CGRP) in the pathophysiology of migraine symptoms, and its neuromodulatory effects. This has led to the development of the new generation of Gepants and CGRP monoclonal antibody (MAB) migraine therapies, including Olcegepant (2000) and Erenumab (2017) which have significant efficacy.

The 60% of patients treated with CGRP MABs have their headache days reduced by ~50%. However, Gepants are still not available on the PBS schedule, while MABs are listed and accessible for patients who have failed multiple standard therapies. These new approaches and correct headache diagnosis will contribute significantly to reducing migraine disease burden.

Diabetic neuropathy (DN) is common, with complications including falls, foot ulcers and potentially amputation. Its MEDICAL FORUM | CANCER CARE

Key messages Nervous system conditions are the most prevalent global causes of Disability Adjusted Life Years (DALYs) Headaches, diabetic neuropathy and stroke are amongst the top five causes. development is associated with raised triglyceride levels, obesity, smoking and hypertension. A high haemoglobin A1c is a significant predictor.

The ACCORD study and EDIC trial found that intensive treatment reduced DN. Beside pharmacological control of diabetes, exercise even over 10 weeks improved nerve function and neuropathy symptoms. Screening for DN is important and can be done easily using a SemmesWeinstein 10 monofilament.

Screening questionnaires and multifaceted screening tools such as the Toronto Clinical Neuropathy Score (TCNS) help improve diagnostic accuracy and selection of patients for more specialised testing. A correlation between DN and corneal nerve fibre density was reported, leading to utilisation of corneal confocal microscopy as a surrogate marker for DN. The ultimate mainstay of prevention remains good diabetic control.

Over the past 25 years, stroke treatment has expanded beyond the conservative use of aspirin.

The ECASS and NINDS tPA trials first showed the benefits of thrombolysis for acute ischaemic stroke. Mechanical thrombectomy has cemented itself as one of the most effective treatments in medicine, with the NNT to prevent disability in one patient with stroke being only 2.3.

Early studies were designed to select patients with the greatest benefit so those with established core infarcts were often omitted.

More trials are now examining the

utility of mechanical thrombectomy in patients with large core infarcts.

A recent meta-analysis of 6 newly completed RCTs using mechanical thrombectomy in patients with medium/large core infarcts showed significant benefits on the Rankin Scale and higher rates of functional independence.

Stroke rates in Australia have decreased by 27% since 2004.

Between 1980 and 2021, annual stroke deaths declined in rate (104 to 24 per 100,000) and number (10,000 to 8500, 16%), driven by several factors, including improved risk factor management and breakthroughs in stroke treatments.

Nonetheless, the opportunity to rescue brain tissue in acute ischaemic stroke is limited by the time to reperfusion (approximately six hours). There remains a continued push to develop novel therapeutic options to prolong this window of opportunity, especially in the Australian clinical setting, where the time and distance to access treatment centres can be long.

The Australian-led phase II, double-blinded, randomised, placebo-controlled multicentre study (SEANCON) to determine the safety, preliminary efficacy and pharmacokinetics of the neuroprotective agent ARG-007 in acute ischaemic stroke patients has recently commenced patient recruitment.

The crux of improving patient outcomes is still early diagnosis and most importantly, patient and community education which will allow patients and doctors to identify and treat these conditions, faster, better and with reduced burdens to patients.

Led by the Institute for Health Metrics and Evaluation at the University of Washington, the Global Burden of Disease study involved researchers from over 150 countries and territories, including Professor Graeme Hankey (Perron Institute Chair in Stroke Research at The University of Western Australia).

Author competing interests – nil AUGUST 2024 | 47

CLINICAL UPDATE

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Non-operative management of hip and knee osteoarthritis

By Dr Arash Taheri, Orthopaedic Surgeon, Mt Lawley Hip and knee osteoarthritis (OA) affects millions globally, significantly impairing their quality of life. Non-operative management strategies have garnered attention for their potential to enhance patient care without the risks associated with surgery, reflecting an updated perspective on OA treatment.

It is important to recognise that we still do not have an allencompassing single aetiology for primary OA, often being multifactorial or ‘idiopathic’. Additionally, radiographic markers of OA do not always correlate with symptomatic OA. Thus, it is imperative to tailor the management to individual patient psychosocial, physical and medical needs, and expectations in a holistic way.

My passion is empowering patients with strategies to avoid joint replacement. Approximately 80% of my new patients will receive some variation of the modalities outlined here, some often avoiding joint replacement for many years. There is much satisfaction in this journey of guided self-improvement for our patients, and I encourage you all to consider trying as many of these as you can within your time constraints.

Analgesics and supplements Non-operative OA management often starts with simple analgesics.

Paracetamol is recommended for initial pain management due to its efficacy at prescribed dosages and safety profile compared to NSAIDs, which offer significant pain relief, but require caution due to gastrointestinal risks.

Emerging evidence highlights the anti-inflammatory properties of palmitoylethanolamide (PEA), while the efficacy of glucosamine and chondroitin remains debated.

However, I still suggest trialling them as there are very little negative side effects. Fish oil and curcumin are recognised for their inflammation-reducing effects, and novel drugs promise innovative approaches to OA pain management.

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Injectables such as corticosteroids provide immediate pain relief, albeit temporarily. Visco supplementation with hyaluronic acid (HA) faces controversy, underscoring the importance of careful patient selection. I use HA only in patients with mild to moderate OA, as sufficient cartilage is necessary for effective hydration.

Current research on plateletrich plasma (PRP) tempers its widespread use due to mixed efficacy results. Similarly, stem cell therapy shows promise, but requires more substantial evidence to justify its cost for routine use in OA treatment.

Lifestyle changes Pro-inflammatory diets are often high in calories, sugars, and unhealthy fats, leading to weight gain, obesity, and metabolic dysfunction. Excess adiposity and metabolic abnormalities, such as insulin resistance and dyslipidaemia, are known risk factors for OA development and progression as well as poorer outcomes.

The evidence suggests that proinflammatory diets may contribute to the exacerbation of symptoms in osteoarthritis patients through their effects on systemic inflammation, metabolic health, joint pathology and cartilage degradation.

Promoting anti-inflammatory dietary patterns rich in fruits, vegetables, whole grains, lean proteins, and healthy fats may help mitigate inflammation, improve symptom management, and slow disease progression in OA patients.

I recommend formal dietetics review for all obese patients.

Weight management plays a pivotal role in alleviating OA symptoms.

The reason is simple – physics! For instance, the knees endure up to 20 times the body weight, while the hips face up to 15 times the body weight. Consequently, even modest weight loss can dramatically reduce joint loads.

I aim to avoid operating on individuals with a BMI over 35, and actively support patients in achieving this target before considering surgery. Many negate the requirement for surgery when they lose the weight.

Intermittent fasting is a strategy I both personally practice and encourage, with a myriad of benefits. The most relevant is the potential anti-inflammatory effects and improvements in metabolic health. Novel pharmaceuticals, including drugs like semaglutide, offer new avenues for weight control. For severe cases, bariatric surgery may be considered, with MEDICAL FORUM | CANCER CARE

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CLINICAL UPDATE exploring alternative therapies studied in the literature including mindfulness and meditation, shown to positively influence pain perception in OA patients.

Key messages Research efforts will likely continue to explore the intricate interplay between psychosocial, genetic, mechanical, inflammatory, metabolic, and age-related factors in OA pathogenesis

Sound therapy, using specific solfeggio frequencies, rhythms and binaural beats, aims to reduce stress and alleviate pain.

Techniques focusing on breath work and positive thinking further enrich the arsenal against OA pain.

Better understanding the complex aetiology of primary OA will pave the way for personalised, targeted therapeutic strategies aimed at preventing or slowing disease progression.

Cognitive Behavioural Therapy (CBT) addresses the psychological aspects of chronic pain, emphasising the importance of mental health in OA management outcomes.

evidence supporting its positive impact on OA symptomatology.

Physiotherapy, emphasising strengthening and flexibility, remains a cornerstone of nonoperative OA management.

Hydrotherapy offers a unique benefit by reducing joint stress during exercise, making it a valuable treatment modality for OA patients seeking pain relief and improved mobility.

In the pool, joint reaction forces are reduced to only three to four times body weight in the knees, allowing

patients to elevate their heart rates while minimising stress on their arthritic joint(s). This creates a synergistic effect that facilitates weight loss.

Other options As an avid practitioner of transcendental meditation and meditating for over a decade, I can personally attest to the vast benefits one receives. I have been

Recognising the limits of nonoperative management is crucial.

When conservative measures prove inadequate in alleviating symptoms and their disability increases, referral for surgical evaluation becomes necessary, ensuring patients receive the most appropriate and effective treatment.

Author competing interests – nil

Relax with Medical Forum at home It can be hard to get downtime at your practice.

Have your free copy delivered to home instead.

www.mforum.com.au

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AUGUST 2024 | 49

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VISUAL ARTS

Peek inside an artist’s studio – and their head More than 100 artist spaces are being opened to the public as part of the much-loved Margaret River Region Open Studios in September.

By Ara Jansen While she has always been creative, it wasn’t until she hit her mid-30s that Nari Jones started pursuing her art with more serious intention. After a particularly difficult time, she took her own medicine and discovered how powerful creating art could be.

Based in Cowaramup, Nari is one of 144 artists who are opening their creative spaces this year as part

50 | AUGUST 2024

of Margaret River Region Open Studios, Australia’s largest open studio event.

Running this year from September 7 to 22, at this free event you’ll be able peek inside the studios and workspaces of painters, potters and printmakers, milliners to mosaicists, timber craftspeople to textile creators and illustrators to installation artists. It’s a rare

experience to get inside an artist’s head and a chance to ask them about their inspiration, process and style, and see where the magic happens.

Their studios are spread across hay sheds and cow barns, inside and around their homes, in purposebuilt idylls, converted water tanks, sea containers and renovated train carriages. Artists who already have

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VISUAL ARTS

WIN Ciao!

The 2024 ST ALi Italian Film Festival returns to Perth October 3 to 27, with films screening at Palace Cinemas Raine Square, Luna Leederville and Luna on SX. As always, the festival presents the best of contemporary and classic Italian films with the full programme set to be released at www.italianfilmfestival.com.au over the coming month.

Medical Forum readers have the chance to win one of five double passes, valid for any film screening at Palace Cinemas Raine Square (excluding special events).

To enter, use the QR code on this page or go to mforum.com.au and hit the competitions tab.

“Making art is always therapeutic for me. I find it’s a way to process difficult things in the world.”

galleries and showrooms take it a further step and invite visitors into their private workshops and back rooms where the creativity usually takes place behind closed doors.

As an occupational therapist, Nari’s art informs her work as much as her work informs her art. The mum to three adult children has a deep reverence for the patterns and cycles of life and nature while honourably dealing with life transitions. Blues and greens are her favourite colours to work in and you’ll also often find labyrinths appear in her mixed media work.

“Ever since my mid-30s I have been called to my reflective practice of creating artwork,” she says.

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Nari has a shed where she can get really messy and splash a lot of paint about. She likens it to making a cake, where she keeps layering on paint and other elements until she’s satisfied before taking it to her studio in the house.

She’ll often work on the floor, layering her work across a piece of canvas, only cutting it to stretch after it’s finished. “I like the freedom of being able to decide how big something will be as I go along, rather than being confined to a square. Some can be as big as two metres by two metres, I can almost walk them.”

The shed is also the place where Nari goes to lock herself in and sit, be still and listen and when she needs answers or direction. A poem, verse or something she has read can often give her an idea for a piece before a visual comes to mind.

“I listen for the muse. That space is a source of inspiration and mystery, a place to sort through the distractions.

“As a young girl I was a runner, and I ran a lot. I found that running was like meditation. While I think it was a bit addictive, I was always in the moment, experiencing the joy of running and going fast. Now art has taken its place and creativity has done the same thing for me. I’m so glad, it’s a lot gentler than running marathons!”

Nari sees her work as storytelling and when someone takes a piece home, they add their own story of why they love it on top of hers. It’s a way to make a connection as well as having the power to transform a space and express things we can’t always speak.

Meet all the artists and plan your studio visits, go to www.mrropenstudios.com.au

AUGUST 2024 | 51

BACK TO CONTENTS

FILM

Snow packs a powerful punch Filmed mainly in Kalgoorlie, the movie Kid Snow is a tough look at relationships and the once popular attraction of tent boxing.

By Ara Jansen Director Paul Goldman didn’t set out to make a classic boxing movie when he signed on for Kid Snow.

While the opening scene – filmed in a pavilion at Claremont Showgrounds – does nod to the Scorsese classic Raging Bull, this movie is really a love story.

It’s about the relationship between two brothers and the woman who comes between them, between a group of mates and between a damaged young couple trying to find their way to each other and hold on.

It’s 1971 somewhere in outback Australia. Washed-up 30-year-old Irish fighter Kid Snow is raising his fists in a raucous travelling tent-boxing show when he’s offered a rematch against the man he fought 10 years ago, now a Commonwealth champion.

It’s Kid’s chance to turn the page on a tragedy that changed his life and perhaps repair the relationship with his brother, who runs the business.

When a feisty single mother named Sunny crosses Kid’s path he is forced to contemplate a future beyond life on the road.

52 | AUGUST 2024

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FILM

“Tent boxing is such a rich part of Australian folklore,” says Goldman who is also co-writer. “I thought it was really compelling. That part of the early 1970s was also a fascinating time for Indigenous men in this country, as many tent boxers were Indigenous.

“It’s also a film about domestic violence. It’s a love story about two brothers dealing with guilt and the woman who comes between them and is running from domestic violence.

“Kid Snow is a raw and simple film which walks an emotional tightrope because of those themes. I didn’t want to make a boxing film – or set out to make Rocky – but I love the world that the story is set in.

I wanted to make a film about relationships.”

The cast includes Phoebe Tonkin, Mark Coles Smith, Hunter PageLochard, Tasma Walton and Robert Taylor.

With the rise of boxing as a legal sport, tent boxing emerged in the early 1900s and boxing troupes toured around Australia’s small towns and outback until the late 1970s. The circus was a world of gaudily painted canvas tents, dirt, campfires, broken down trucks and rough sleepers.

It was a carnival-like roadshow patched together with booze, tape and glue where rough-as-guts professional tent fighters faced off against local challengers. It was a place where everyone and all skin colours were welcomed, local legends were born, and Indigenous fighters became heroes in their own

communities. These events also often featured ‘leg shows’ where women danced and entranced audiences before they went into the boxing tent.

Kid Snow features a real boxing tent, which belongs to Michael Karaitiana, a third-generation promoter and a bona-fide showman still delivering the legendary nomadic fight show started by his grandfather Roy Bell in 1924. Michael was born in Roy Bell’s Touring Stadium – the oldest original boxing troupe still touring Australia. He runs the tent the same way his grandfather did almost 100 years ago.

Michael drove this almost 100-yearold tent from his farm in far north Queensland across to WA, bringing with him a myriad of treasures which the film’s production department would use when creating the film’s showground locations in Kalgoorlie and Coolgardie.

The harsh Goldfields landscape also plays a significant part in Kid Snow. Rather than using the picture postcard glaring sun, lots of the film takes place at night and the light of day is hazy, seen almost through smudged glass.

ED: Kid Snow opens at cinemas on September 12.

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AUGUST 2024 | 53

medical forum CLASSIFIEDS EQUIPMENT FOR SALE PERTH AIRPORT Skin Cancer Clinic Equipment Sale Contact: Yvonne 0468 43 45 47 Date of Viewing/Sale/Pick-Up: Sat, 13th, 20th & 27th July 2024, 9:30 am – 12:00 noon Location of Sale Site: Storage Units D05 & D07, Storage King, 19 Bungana Ave, Perth Airport, 6105 Payment: Cash or Direct Bank Transfer; No Credit Cards or Cheques Items: Used but in very good working order, unless stated. All offers will be considered respectfully.

• Pellevé machine/Surgitron Dissector.

[Ellman S5] RRP $24,999, SurgiCart RRP $1,500, Pelleve Glidesafe (10,15,20mm) pens (each $$363), Thermal temperature gun RRP $350 & Gel included.Total RRP $28,900 Selling $8,000 ONO • Multiple Electrodes (for cosmetic & surgical procedures), Needles & finger & foot handpieces. RRP $6300, Selling for 1,000 ONO • Smoke Evacuator for dissector machines (virtually essential for Pellevé machine/Surgitron Dissector) RRP $3200, Selling $900 ONO • Aaron Bovie 900 Cautery/Dissector machine, with footswitch, multiple pens & attachments (Adson Bipolar Forceps & Cable). Total RRP $3030, Selling $900 ONO • Athlegen Pro-Lift Venus Extend hydraulic procedure beds x 2. Plus 3 layer premium 10cm memory foam padding, pale & dark blue (with adjustable face, head, shoulders, arms & feet attachments & extensions.

Current RRP $7,700 per bed & all attachments. Selling each bed for $2,000 ONO • Day surgery hydraulic bed x1 (HBA Electric) with a mobile rechargeable power pack, hydraulic lift or direct power plug (Power pack needs a service). RRP $4,600 Selling for $800 ONO • Melag Premium Classic Vacuklav 43B Autoclave, 22L + 2 Support racks, (Installed & regularly serviced by IBES Australia), RRP New is $19,685; Selling for $5,000 ONO • Large Surgical Light, Midmark Ritter 355 Theatre Light on a movable stand (with 20+ spare light bulbs) RRP $4785 + (Bulbs at $26 x 20) = $530.

Selling $900 ONO • Taylor-Wharton Liquid Nitrogen Dewar, 25L $2151 on a roller base $578 + metal dipper $230, Selling all $1100 ONO • Taylor-Wharton Liquid Nitrogen Dewar, 4L, RRP$1250 Selling $200 ONO • Blood Centrifuge (+ Consumables for PRP) RRP $2100, Selling all $500 ONO • Fujitsu: Kyocera Colour Multi-Function Printer (MFP) + Toner Ink RRP $2300 Selling $550 ONO • Multiple Cabinets, Chairs – office & waiting room, Desks, Shelves, Tables Fridge, & Sundry items, Best Offers.

FOR SALE

MURDOCH SJOG Murdoch – Consulting Suite for Sale – TWO GENEROUS CONSULTING SUITES – FURNISHED SUITE AT SJOG MURDOCH Sterling Property is delighted to offer 47 / 100 Murdoch Drive, SJOG Murdoch for Sale.

This generously proportioned furnished consulting suite comprises of 97 sqm, configured with two large consulting rooms, reception and waiting area.

Onsite on SJOG Murdoch and a short walk to Fiona Stanley Hospital.

Asking Price : $880,000 + GST (Includes Leased Car Bay) Contact Simon Brady from Sterling Property on 0407 486 401 sbrady@sterlingproperty.au

79

REGIONAL PLACEMENTS

HARVEY Treendale Medical Group – GP Positions • DPA Area’s and MMM5 Available • FSP GP’s are welcome to apply • Busy & well established Medical Group with 4 Location in the South West of WA • Full time & Part Time GP Positions in Treendale & Harvey • Fully computerized and accredited modern practice with nursing and admin support • Well supported with large team of experienced GP’s • Situated in the beautiful South West Region surrounded by coast and forest and close to tourist areas in the south of WA • Only 1 ½ hrs from Perth • Family friendly working hours and no on call or hospital cover required • 65 – 70% of billings depending on experience Please forward CV and enquiries to Kylie Wilson kyliew@harveymed.com.au

FREMANTLE P/T GP required for our friendly practice in the heart of Fremantle. Young demographic with lots of student health, sexual health, women’s health and mental health.

Fully equipped, accredited practice with full time practice nurse and onsite pathology, 2-3 days/week, days negotiable.

Contact Stephen on 0411 223 120 or at stephen@westendmed.com.au

COMO

METRO PLACEMENTS

Opening for VR GP - F/time or P/time Full Private List available now from retiring GPs FRACGP essential Up to 70% private billings Unique opportunity to join our family orientated practice in one of Perth’s fastest-growing suburbs.

Enjoy working for a doctor-owned, non-corporate, well supported, and accredited practice.

Please contact the Practice Manager on 6165 2444 or email: reception@comogp.com.au

Central City Medical Centre Full time or Part-time VR GP Private doctor-owned medical centre, providing excellent medical services to our patients for 35 years.

We offer: • Excellent earning potential as a private billing Medical Centre • Experienced administrationmanagement team • Convenient proximity to the CBD • Hourly retainer for the first few months while you settle in and build your own patient base • Full-time doctors have exclusive use of their own room and part-time doctors would share with another part-time doctor.

Contact the Practice Manager, Claire Stocks, on 0422 511 906 or claires@ccmc.net.au

MOUNT PLEASANT Queens Road Surgery is a busy GP owned general practice located in Mount Pleasant.

We are looking for a VR GP to join our well established practice.

We offer a supportive team based culture, experienced administrative staff and quality full time nursing support.

Queens Road Surgery is a fully equipped accredited practice.

For a confidential discussion please contact our Practice Manager Narelle 0412 113 584 or narelle@queensroadsurgery.com.au

FOR LEASE

NEDLANDS Suite 39, HOLLYWOOD MEDICAL CENTRE, Nedlands • Furnished, generously proportioned Consulting room available for specialists.

• Currently available Tuesdays and Wednesdays on sessional basis.

• Half day or full day, depending on requirements.

• On second floor of the exclusive Hollywood Medical Centre.

• Corner suite with exceptional views, reception, waiting area and kitchenette.

• Onsite on Hollywood Private Hospital, with Cafe and all other amenities • Dedicated undercover car bay available for parking • Easy patient parking in multi-storey car park • Admin/Secretarial support requirements can be discussed A unique opportunity to have a prestigious practice location long term!

For more details or to view, contact Amit on 0451824144 or Email Admin@dramitsaha.com.au

CONNECT WITH US classifieds@mforum.com.au (08) 9203 5222

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NEXT DEADLINE: For Classifieds, contact Ross Bulman – Tel 9203 5222 or classifieds@mforum.com.au

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medical forum CLASSIFIEDS

Office Space Available for Lease COTTESLOE – Brand New Medical Centre Seeking GPs Soleil Health, the future hub of unparalleled medical care and holistic well-being, is on the lookout for passionate and skilled General Practitioners to join our dynamic team in Cottesloe. As we prepare to open our doors in August 2024, we invite you to be a part of a healthcare revolution that prioritises clinical excellence, patient well-being, and a collaborative work environment.

About the Role: As a General Practitioner at Soleil Health, you’ll experience clinical autonomy, allowing you to practice on your own terms. Our commitment to providing the best healthcare is reflected in the use of Best Practice Software, ensuring streamlined and efficient processes. Embrace a collegial and collaborative culture where teaching and education are at the forefront of our mission.

GPs working for the practice also have the opportunity to provide home visit service to the neighbouring aged care residences.

Key Highlights: Clinical Autonomy: Have the freedom to practice medicine focusing on your special interest.

Best Practice Software: Utilise cutting-edge tools to enhance the efficiency of your practice.

Collegial Culture: Engage in a collaborative environment, emphasising teaching and education.

Private Billing: Be a part of a practice that values your expertise with a private billing model.

About the Requirements: Current unrestricted registration with the Medical Board of Australia / AHPRA VR status with Medicare AHPRA Registration Valid working rights in Australia

Phone 0493 977 301 Email Manpreet.kaur@soleilhealth.com.au

Located in the heart of Willetton, at the corner of Pinetree Gully Road, and Burrendah Boulevard, the available office space is within the compound of Willetton Medical Centre.

Features 48sqm with ensuite toilet New Fittings – lighting, air conditioning, storage Separate entrance to the main building 2 reserved car park spaces for tenant Wall to wall advertising opportunity Please contact Willetton Medical Centre on 93101234 for more information or to arrange a viewing.

soleilhealth.com.au

We’re seeking a Clinical Lead General Practitioner Mosman Park Medical Centre is a GP owned practice. We are looking for another GP to join us.

We have six consulting rooms and it is a lovely calm, caring environment with a great patient base.

We are close to all amenities including shopping, cafes, beaches and river.

This can be a full-time or part-time position with scope for all GP areas of interest.

Our team of friendly receptionists is complemented by two experienced practice nurses at all times.

KALGOORLIE – The RFDS WA Strategy 2024 – 2028 strives to make a positive difference to the health and well-being of people living and working in regional WA. One of the focus areas will be to expand Primary Health Care services for a bigger community impact, with an initiative to establish an inaugural RFDS GP Clinic in Kalgoorlie, partnered with the Kalgoorlie Campus of the Curtin Goldfields University Department of Rural Health.

We are looking for a Clinical Lead General Practitioner, who will provide clinical leadership for the RFDS General Practice Clinic supporting the delivery of high-quality care to patients and the community.

Please contact Lauren.Dawe@rfdswa.com.auau

For more information please contact admin@mosmanparkmedicalcentre.com.au

NEXT DEADLINE: For Classifieds, contact Ross Bulman – Tel 9203 5222 or classifieds@mforum.com.au

rfdswa.com.au

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MEDICAL FORUM | CARDIOVASCUL AR HEALTH

medical forum CLASSIFIEDS

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New Challlenges New Exxperien nces

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wheatbelt.com.au

Join Doctor Northbridge: A Premier GP Opportunity in Perth!

Are you a GP seeking an exceptional opportunity in Perth’s bustling CBD? Look no further! Doctor Northbridge, a private doctor-owned practice, is offering a dynamic VR GP position in one of the city’s most sought-after locations. Our state-ofthe-art medical centre, nestled within heritage-listed buildings, boasts top-notch facilities and a supportive environment.

Enjoy the perks of: High-earning potential with private billing Highly-trained administrative team Private billing practice with excellent earning potential On-site parking and convenient proximity to Perth CBD Strong nursing support and low Did Not Attend (DNA) rate 65% of Billing with a Minimum Guarantee of $200 per hour for 3 months Part-time or full-time opportunities available With over 100 new patients a week and effective marketing strategies driving growth, Doctor Northbridge is the perfect place to advance your career. Join us and be part of a collegial environment dedicated to excellence in patient care.

Contact us today to learn more and schedule a visit!

Dr Yoon Low | Phone: 0431299328 Email: careers@drnorthbridge.com.au www.drnorthbridge.com.au

Wheatbelt

Health Network

Full time replacement required for retiring principal GP

Join our Busy Mixed-Billing Medical Centre in Perth’s Northern Suburbs Start Immediately and Be Busy from Day One! We are seeking a skilled and dedicated GP to join our dynamic team in Perth’s northern suburbs. As a valued member of our medical centre, you will:

I am retiring in October after 38 years as a GP. I have a loyal following of patients and am always fully booked.

I have special interests in mens and women’s health, sexual health, mental health and skin cancer surgery.

West End Medical is a boutique practice in the heart of old Fremantle. It is fully equipped and computerised (BP) with experienced staff and on-site pathology. The practice is accredited, private billing and non-corporate.

This is a huge opportunity for a VR GP to take over an established patient list with high earning potential with an opportunity to become a co-practice owner. I am happy to offer mentoring to anyone interested in developing their sexual health skills.

Key Responsibilities: Provide a full range of GP services, including health assessments, chronic disease management, and minor surgical procedures Collaborate with our multidisciplinary team to achieve the best patient outcomes Utilize our on-site specialized Mole & Skin Cancer Clinic, Allied Health Services, and Pathology Work in a fully computerized environment with the latest technology (Best Practice) Training practice for GP Registrar.

Requirements: AHPRA registration FRACGP or equivalent and VR. What We Offer: Flexible working hours with full-time and part-time options Competitive remuneration with percentage earnings Supportive and friendly team environment Modern facility with state-of-the-art equipment Fabulous career opportunities for experienced GPs.

For further information contact Stephen Adams on 0411223120 or stephen@westendmed.com.au or Dovida Hickey on dovida@westendmed.com.au

westendmed.com.au

Get in Touch: Call Nash on 0433 400 792 or Julius on 0400 016 257 for a discreet and confidential chat. Alternatively, email nash.qamar@gmail.com to learn more.

Let’s work together to provide exceptional patient care!

NEXT DEADLINE: For Classifieds, contact Ross Bulman – Tel 9203 5222 or classifieds@mforum.com.au

An amazing lifestyle opportunity for GPs Our beachside practice in Albany is looking for new GPs

FRACGP preferred, flexible arrangements Relocation assistance offered Large and diverse patient base, mixed billing

Your own spacious room Fully computerised and Doctor owned No on call or after hours

For a confidential discussion about your next career move, call Jean at 0400 605 529 or email jean.paradise@breckenhealth.com.au