Medical Forum – May 2021 – Public Edition

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No more silence!

Women’s Health | Cervical screening, fertility, breast cancer, testosterone, contraception

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May 2021 www.mforum.com.au


Dr Fiona Langdon Obstetrician and gynaecologist, WA

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EDITORIAL BACK TO CONTENTS

Cathy O’Leary | Editor

Women speak out Collectively they have put new focus on the inconvenient truth of sexual violence against women, some of which has been dismissed in the past as the harmless antics of men behaving badly.

With all eyes on the bumpy vaccine roll-out to stop COVID-19 in its tracks, you might have thought there was no capacity or energy to fight any other battles. But that was before claims of sexual violence and misconduct rocked Canberra, hot on the heels of an impassioned speech by Australian of the Year Grace Tame, a remarkable survivor of sexual abuse at the hands of her maths teacher. Collectively they have put new focus on the inconvenient truth of sexual violence against women, some of which has been dismissed in the past as the harmless antics of men behaving badly. Women appear to have had enough, with more coming forward to report current or historic sexual abuse. As we reveal in our cover story, that means GPs need to be prepared for patients walking through their doors asking for help. There is plenty more to read in our bumper Women’s Health edition. Hear from those who have endured unrelenting gynaecological pain (and come out the other side), as well as women accessing surrogacy services who face discrimination because they are not considered “real mums”. And read about the social phenomenon known as ‘eggsurance’ where young women pay the equivalent of a Netflix subscription to freeze their eggs. It’s done in the hope it will kick the fertility can down the road a few years until they are ready to have a family. Interestingly, only one in 10 of them end up using their eggs, but I guess that’s the nature of insurance – it’s there ‘just in case.’

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 Medical Forum WA as an independent publication for health professionals in Western Australia. The support of all advertisers, sponsors and contributors is welcome. Neither the publisher nor any of its servants 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. 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. Advertisers are responsible for ensuring that advertisements comply with Commonwealth, State and Territory laws. It is the responsibility of the advertiser to ensure that advertisements comply with the Competition and Consumer Act 2010 as amended. All advertisements are accepted for publication on condition that the advertiser indemnifies the publisher and its servants against all actions, suits, claims, loss and or damages resulting from anything published on behalf of the advertiser. EDITORIAL POLICY This publication protects and maintains its editorial independence from all sponsors or advertisers. Medical Forum has no professional involvement with Tego Insurance Pty Ltd and Noble Oak Life Insurance other than as publisher of its promotional material, which is inserted in this month’s magazine. Medical Forum cannot and does not endorse any of its products.

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MAY 2021 | 1


CONTENTS | MAY 2021 – WOMEN'S HEALTH

Inside this issue 12 20 24 30 FEATURES

NEWS & VIEWS

LIFESTYLE

12 Women speaking up

1

66 Painting a picture

20 Vaccines – a miracle in the making

24 GPs and pharmacists – collaborators or competitors?

30 Close-Up: Dr Christabel Samy

Time for change – Cathy O’Leary

of remote medicine – Dr Lindsay Green

4 In the news 6 In brief

68 From pain comes a shared truth – Cathy O’Leary

28 Breast researchers look to genes

34 Q&A Hannah Pierce – Public Health Association WA

36 The misogyny of iron

70 State of the Arts – Ara Jansen

71 Wine Review: Aphelion Wines – Dr Martin Buck

deficiency

45 Going beyond labels – Dr Joe Kosterich

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CONTENTS

PUBLISHERS

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Karen Walsh – Director Chris Walsh – Director chris@mforum.com.au

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EDITORIAL TEAM

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COVID-19 & the National Cervical Screening Program Dr Adeline Tan

Radiation oncology for early breast cancer Dr Yvonne Zissiadis

To freeze or not to freeze? Dr Rose McDonnell

‘Where have my periods gone?’ Dr Tamara Hunter

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OMG! O-RADS and IOTA ADNEX are here Dr Emmeline Lee

Heart Disease in Women Dr Michelle Ammerer

Testosterone therapy in postmenopausal women Dr Ashley Makepeace

Multidisciplinary care for breast cancer patients Dr Arlene Chan

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Navigating the maze of fad diets Jo Beer

Contraceptive implants update Dr Alison Creagh

Keeping an open mind diagnosing cervical disease Dr Jenny Grew

Perinatal Depression and anxiety and breastfeeding support Caroline Munchenberg

Editor Cathy O'Leary 0430 322 066 editor@mforum.com.au Journalist Dr Karl Gruber (PhD) 08 9203 5222 journalist@mforum.com.au Production Editor Ms Jan Hallam 08 9203 5222 jan@mforum.com.au Clinical Editor Dr Joe Kosterich 0417 998 697 joe@mforum.com.au Clinical Services Directory Editor Karen Walsh 0401 172 626 karen@mforum.com.au

GRAPHIC DESIGN Ryan Minchin ryan@mforum.com.au

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Let’s make COVID count for women Dr Michael Gannon

What surrogacy means for women Nadeen Laljee-Curran

Asbestos: not bound by borders Jo Morris

Women’s business can’t remain secret Kath Mazzella

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Eyeing off diabetes in kids

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IN THE NEWS

Isabelle Piercey at the eye clinic

A new eye clinic at the Lions Eye Institute, set up to treat children and adolescents, will help to reduce blindness in WA children with diabetes. The clinic is a collaboration between the LEI and Perth Children’s Hospital and is part of the new Perron Paediatric Retinopathy Initiative, supported by the Stan Perron Charitable Foundation. It includes the new clinic and a significant research project that will help develop new therapies to reverse sight-threatening complications due to diabetic retinopathy. With referrals from PCH’s departments of endocrinology and diabetes, and ophthalmology, LEI ophthalmologists Associate Professor Chandra Balaratnasingam and Dr Antony Clark will screen, assess and treat children for juvenile diabetic retinopathy complications.

Mums shrug COVID concern Doctors, midwives and midwifery students were more concerned about their exposure to COVID-19 while at work than the women receiving maternity care in the same settings, Curtin University research has found. As national and international health leaders consider how to best provide maternity care in a post-COVID world, the research has produced the firstknown evidence of the varied experiences of people involved in receiving and providing maternity care during the pandemic. The research involved a survey of 3701 women, their partners, midwives, medical practitioners and midwifery students who had received or provided maternity care from March 2020 onwards in Australia. Lead author Dr Zoe Bradfield from Curtin School of Nursing said pregnant women and new mothers were most concerned about the general threat of COVID to them, their babies and their families, but less concerned about exposure to the virus through medical or health settings than the doctors and midwives working in these environments.

Chasing a good night’s sleep New trials at the University of Western Australia may offer hope to sufferers of sleep apnoea who struggle to get a full night’s sleep 4 | MAY 2021

without disruption. Sleep apnoea is the second most common sleep disorder affecting about 50 per cent of people over the age of 50 and occurring when the airway or throat narrows or completely blocks during sleep. The current most effective way of treating sleep apnoea is via a continuous positive airway pressure (CPAP) machine that blows air into the upper airway passages. But fewer than half of patients go on to use it long term. UWA’s Centre for Sleep Science is seeking volunteers to take part in one of two current trials investigating two new treatments that are possibly more tolerable than CPAP yet still effective for users. Centre director Dr Jen Walsh said there was a need for new sleep apnoea therapies for people who struggled with existing options. The centre is looking for volunteers (up to 75 years old) who have obstructive sleep apnoea but are not regularly using any treatments. Those interested can phone 6488 4604 or 0447 591 894, or email sleepscience-aphb@uwa. edu.au.

New day hospital for Midland The State Government helped launch the new Midland Day Hospital, a $15 million investment by Health Integra, with Premier Mark McGowan and Health Minister Roger Cook attending the event. Health Integra director Dr Amitha Preetham said the new facility would provide

access to high standard of care day surgery and specialist consulting services. The second floor is leased to day surgery tenant St John of God Health Care and will accommodate one of Australia’s largest day surgeries, with operating theatres and a procedure room.

Falling foul Fashion icon Carla Zampatti’s recent death from a fall has put the spotlight on the dire consequences of a misjudged step or loss of balance. Falls in older adults can cause serious and life-threatening injuries and are a major source of concern for their family carers. Hollywood Private Hospital is investigating the impact of falls in older patients on their family carers. Edith Cowan University nurse researcher Marcus Ang said many carers experienced longterm psychological distress due to the fear of their loved one falling and becoming injured. “We hope to understand more about the falls experiences of family carers before, during and after hospitalisation of older patients,” Dr Ang said. “Understanding carers’ falls concerns is crucial to determine if they are coping with the provision of care or have adequate knowledge and support in preventing falls.” About 180 family carers and continued on Page 6

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The impact of COVID-19 on the National Cervical Screening Program The COVID-19 pandemic has affected all aspects of life “as we know it” – the social and economic ramifications are still unfolding and will continue for many years to come. Insights on various women’s health issues have been raised including the impact of COVID-19 on the National Cervical Screening Program (NCSP). Together with the HPV vaccine given under the National Immunisation Program, it is hoped that cervical cancer will be eradicated. But are we still on track? In March 2020, a modelled analysis of hypothetical impact on the NCSP was commissioned by the Australian Department of Health and submitted on 1 May by Cancer Council NSW. Unlike other countries such as New Zealand and the United Kingdom, the NCSP or HPV vaccination services in Australia did not experience any official pausing. However, there are still some disruptions as a result of the lockdowns and other reasons including personal illness or caring for someone with an illness, increased childcare responsibilities, changes in work responsibilities and reluctance to visit their GP due to concerns about COVID-19 exposure. In mid-March 2020, the NCSP was 27 months into transition from a twoyear to a five-year recommended screening interval. The effect of this timing is that fewer women were expected to attend for a routine primary Cervical Screening Test (CST) in 2020 than in the 2019 or earlier years. However, the women who would have also attended in 2020 were already overdue for screening (and as a result a higher risk group).

COVID-19. The modelled analysis uses a well-established simulation model of human papillomavirus (HPV) natural history and cervical screening, the possible/hypothetical disruption and estimated potential impacts of the disruption on attendance on cancer diagnosis (including stage at diagnosis), increased numbers of colposcopies and the long-term sequelae of additional or upstaged cervical cancers diagnosed over 2020-2022. Three scenarios were modelled (12-month period with 95% reduction; nine-month period with 75% reduction; and six-month period with 50% reduction of women attending a primary test).

Findings Under these scenarios, potentially 270,378 to 1,027,437 women could miss out on a primary CST in 2020 due to COVID-19 disruptions. All three scenarios resulted in an increased number of cancer diagnoses among screening-age women over the period of 20202022, from 21-69 cases (1.1-3.6% increase). The largest increase in cancer diagnoses would be among women aged 30-39 and 40-49 years. It will also lead to cervical cancers being diagnosed at a later stage, when survival outcomes are less favourable (approximately 6-18 cases upstaged from localised to regional; approximately 3-9 cases upstaged from regional to distant). The additional cervical cancer

The decrease in CST numbers is expected, but also potentiated with

Dr Adeline Tan

About the Author Dr Tan is a specialist gynaecological histopathologist and cytopathologist. She is a Senior Clinical Lecturer at UWA and is a pathology reviewer for the Western Australia Gynaecological Oncology (WAGO) biobank, St John of God Gynaecological Cancer Research and the Ovarian Tumour Tissue Analysis (OTTA) consortium.

cases diagnosed at a later stage (30-97 women) would lead to approximately 6-20 more cervical cancer deaths. To reduce the impact of these effects, a broader option of testing such as self-collection may be required. There will be targeted communication to the 30-49 year age group in May/ June 2021. Colposcopy demand is also expected to increase in 2021-2022 compared to what have been expected in the absence of a disruption, due to the delay in “intermediate risk” women attending their 12-month follow up. Public and private colposcopy providers should have available resources to respond to this predicted increased demand. Finally, all health professionals should remain vigilant with follow-up for women under CST surveillance and provide timely referral/investigations for women presenting with symptoms, keeping in mind that COVID-19 may have already contributed to a delayed diagnosis at the time of presentation. Reference: https://www.health.gov. au/resources/publications/modelledanalysis-of-hypothetical-impacts-ofcovid-19-related-disruptions-to-thenational-cervical-screening-program

Main Laboratory: 310 Selby St North, Osborne Park General Enquires: 9371 4200 Patient Results: 9371 4340 For information on our extensive network of Collection Centres, as well as other clinical information please visit our website at

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Pharmaxis has announced a world-first clinical trial of a treatment to prevent wound and burn scars, led by burns expert Professor Fiona Wood and UWA researchers. It has the potential to transform trauma recovery by blocking the underlying fibrosis that causes scar tissue.

IN THE NEWS

continued from Page 4 patients will be recruited for the study, which is due to start in June. If successful, Dr Ang hopes the carers’ questionnaire will be used as an alternative risk assessment tool to predict the fall risk of older patients from the perspective of their family carers.

Go for green Cancer Council Australia has produced fact sheets on less common cancers to help health professionals and their patients. It is estimated that rare cancers, including soft tissue sarcoma and gall bladder cancer, affect about 52,000 Australians each year. Details are at cancer.org.au/ cancer-information/types-ofcancer/rare-cancers

Eating one cup of leafy green vegetables every day could boost muscle function, according to new Edith Cowan University research. The study, published in the Journal of Nutrition, found that people who consumed a nitrate-rich diet, predominantly from vegetables, had significantly better muscle function of their lower limbs. Poor muscle function is linked to greater risk of

falls and fractures and is considered a key indicator of general health and wellbeing. Researchers examined data from 3759 Australians taking part in Melbourne’s Baker Heart and Diabetes Institute AusDiab study over a 12-year period. They found those with the highest regular nitrate consumption had 11 per cent stronger lower limb strength than those with the lowest nitrate intake. Up to 4 per cent faster walking speeds were also recorded. Lead researcher Dr Marc Sim from ECU’s Institute for Nutrition Research said the findings reveal important evidence for the role diet plays in overall health. While leafy greens may be some of our least favourite vegetables, they could be the most important, according to Dr Sim.

continued on Page 8

Physiotherapist Claire Tucak puts ‘PD Warrior’ John Haselhurst through his paces.

Kimberley-based Aboriginal community-controlled and government health services, research institutes and universities have united to form the Kimberley Aboriginal Health Research Alliance, with the objective of improving and promoting the health and wellbeing of Aboriginal people through practical health research. It will be chaired by respected Aboriginal leader Mick Gooda.

The Stroke Foundation says new guidelines have been developed with effective rehabilitation techniques for leg and arm weakness after stroke, providing greater direction for health professionals and improved patient outcomes. They are available at www. strokefoundation.org.au

6 | MAY 2021

Help for Parkinson’s A research study at Hollywood Private Hospital will investigate the impact of the exercise program PD Warrior on patients with Parkinson’s disease. The program involves intensive exercises designed to retrain the brains of people with the nervous system disorder. The specific exercises aim to improve mobility and function to help participants gain better control over their movements. The research project will look at the quality of life of participants and objective measures, such as mobility and balance, before and after they take part in the PD Warrior program. The study is being conducted by neurologist Dr Julian Rodrigues, with neurological physiotherapist Claire Tucak, who said the program had the potential to be a game-changer for patients with Parkinson’s. The study will provide data on both subjective and objective outcomes before and after a 10-week PD Warrior program. The results are expected at the end of the year. Meanwhile, more than 20,000 Australians under 50 years of age living with Parkinson’s are set to benefit from the launch of an Australian-first digital support platform. Developed as a ‘living lab’ model, the Young Onset Parkinson’s Exchange (YOP-X) is a free-to-download app and resource hub uniquely shaped by the first-hand knowledge and experiences of Australians living with young onset Parkinson’s disease. Available to patients, carers, healthcare professionals and NDIScontracted providers, the YOP-X app can be downloaded for free from the App Store or Google Play. MEDICAL FORUM | WOMEN ’S HEALTH

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IN BRIEF


Stop heavy periods. Period.

Fact: 1-in-5 women suffer from heavy periods.1 As recommended in the Heavy Menstrual Bleeding Clinical Care Standard, uterine-preserving procedures should be the first-line surgical treatment for women who have completed their childbearing. 2 Informed choice is also recommended. When presenting options to your patients, consider the NovaSure® endometrial ablation: 5 minute procedure* Minimally-invasive alternative to hysterectomy Effective in 9-in-10 patients3–4

www.novasure.com *The NovaSure ® procedure is performed by a gynaecologist. Precisely measured radiofrequency energy is delivered for an average of 90 seconds, and the entire procedure typically takes less than 5 minutes to complete.4 References: 1. National Women’s Health Resource Center (United States). Survey of women who experience heavy menstrual bleeding. Data on file, 2005. Based on women aged 30–50 years. 2. Australian Commission on Safety and Quality in Health Care, Clinical Care Standards, Heavy Menstrual Bleeding, October 2017. 3. Cooper J, et al. A randomized multicenter trial of safety and efficacy of the NovaSure system in the treatment of menorrhagia. J Am Gynecol Laparosc. 2002;9:418-428. 4. NovaSure ® Instructions for Use. Bedford, MA: Hologic, Inc. ADS-02748-AUS-EN Rev.002. © 2020 Hologic, Inc. All rights reserved. Hologic, NovaSure and associated logos are trademarks and/or registered trademarks of Hologic, Inc. and/or its subsidiaries in the United States and/or other countries. This information is not intended as a product solicitation or promotion where such activities are prohibited. Because Hologic materials are distributed through websites, eBroadcasts and tradeshows, it is not always possible to control where such materials appear. Hologic (Australia and New Zealand) Pty Ltd, Suite 302, Level 3, 2 Lyon Park Road, Macquarie Park NSW 2113. Tel. +61 2 9888 8000. ABN 95 079 821 275.

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continued from Page 4

Soap as good as fancy stuff Soaps that claim to be antimicrobial or antibacterial are no better than ordinary soaps and are feeding the growing superbug problem and should be banned, Monash University researchers say. Demand for household soaps with antimicrobial additives has spiked during the pandemic, with consumers duped by the false premise that they provide superior protection against germs and disease. Professor Trevor Lithgow, director of Monash University’s Centre to Impact AMR, says ordinary soap and water is an effective hand hygiene solution and reduces unnecessary exposure to chemicals that are feeding antimicrobial resistance and creating superbugs. Superbugs are predicted to kill 10 million people a year by 2050, including tens of thousands of Australians. While overuse of antibiotics is also driving these superbug infections, antimicrobial soaps and detergents are a contributing factor and should be banned, Professor Lithgow said.

Physio pays off A report released by the Australian Physiotherapy Association argues there is strong evidence of the cost effectiveness and improved quality of life from physiotherapy interventions. An independent analysis undertaken by the NOUS Group showed the economic benefits that physiotherapy

Recognising our best The recent WA Rural Health Awards recognised the cream of the crop among WA’s rural doctors. Supported by Rural Health West and the WA Country Health Service, the top gongs included GP of the Year Dr Samantha Weaver (left), Specialist of the Year Dr Charles Greenfield (centre), Procedural GP/ District Medical Officer of the Year Dr Peter Smith, and Rising Star Dr Caitlyn White (right).

provided to patients and the Australian healthcare system. The report analysed the impact of physiotherapy on 11 common conditions including osteoarthritis of the hip and knee, falls prevention programs, back pain, and a diverse range of other health conditions affecting millions of Australians.

Drugs not always the answer Doctors should consider more social prescribing of non-drug approaches for depression and loneliness, say researchers. Non-drug therapies, such as exercise, appear to be as, or more, effective than drugs for reducing symptoms of depression in people with dementia, according to research published online in the BMJ. The findings suggest

that people with dementia gain a clinically meaningful benefit from non-drug interventions. Previous trials have shown that approaches such as exercise alleviate symptoms of depression in people with dementia, but it has not been clear how effective they are compared with drugs to reduce symptoms of depression. To address this uncertainty, researchers analysed the results of existing trials to compare the effectiveness of drug and non-drug interventions with usual care or any other intervention targeting symptoms of depression in people with dementia. After screening 22,138 records, they reviewed 256 studies involving 28,483 people with dementia, with or without a diagnosed major depressive disorder.

More drugs to combat Duchenne A third treatment developed by a WA research team to treat Duchenne muscular dystrophy has received accelerated approval by the United States Food and Drug Administration. American biopharmaceutical company Sarepta Therapeutics said the drug casimersen had the potential to treat eight per cent of patients with Duchenne by skipping exon 45 during dystrophin expression. Casimersen and the two other gene-patching drugs approved by the FDA for Duchenne were developed through the pioneering research of Professors Steve Wilton and Sue Fletcher at the Perron Institute and licensed through the University of Western Australia. Each drug is designed to treat a specific type of dystrophin gene mutation and this required testing in separate clinical trials. Duchenne muscular dystrophy, occurring mainly in boys, is the most common childhood form of muscle-wasting and is caused by a genetic error that prevents the body from producing dystrophin, a protein essential for maintaining muscle fibre strength and stability. Most children with Duchenne require a wheelchair before their early teens. Billy Ellsworth, pictured with Professors Wilton and Fletcher, received treatment with the first Duchenne drug, eteplirsen (Exondys 51) and is now aged 20 and still able to walk. This initial exon 51 skipping drug targets about 10-13 per cent of Duchenne patients.

8 | MAY 2021

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IN THE NEWS


Current status and future perspectives in radiation oncology for early breast cancer Dr Yvonne Zissiadis is a radiation oncologist subspecialised in breast cancer and the medical director of GenesisCare Hollywood.

Radiation therapy plays an integral part in the management of breast cancer. Dr Yvonne Zissiadis shares her knowledge in the early breast cancer setting. Why do many early breast cancer patients need radiation therapy? The quick answer is that all early breast cancer patients derive benefit from radiation therapy (RT), but some more so than others. Over the last 16 years, four key studies¹,²,³,⁴ have shaped our current understanding of the benefits of RT in this setting. These studies overwhelmingly show that the addition of RT reduces a patient’s risk of recurrence and breast cancer death.* How have treatment techniques improved in recent years? The development of new technology and imaging has enabled a dramatic shift and not just for breast cancer. Volumetric modulated arc therapy (VMAT) fires multiple radiation beams around the entire tumour from all angles to within one-millimetre accuracy while reducing the dose to normal tissues and avoiding critical structures. This has translated into enhanced accuracy and a reduction in side-effects. In breast cancer specifically, GenesisCare was first in the state to introduce deep inspiration breath hold (DIBH), a technique now commonly used to reduce the risk of radiation to the heart. Most early breast cancer patients are now being considered for a ‘hypofractionated’ technique which reduces the number of treatments. Soon, new technology will allow selected patients to do away with the small tattoos that assist positioning; and finally, in collaboration with SJOG Subiaco, suitable low-risk breast patients can elect to receive RT intraoperatively rather than daily over several weeks. What is the future of radiation therapy in breast cancer? While different fractionation schedules are being explored and further advances in imaging technology are expected, the future of oncology lies in the genetic understanding of tumour characteristics to guide treatment decisions. In the future, specific molecular profiling will be used in addition to the traditional pathological and clinical factors to guide treatment decisions for clinicians and patients. This is precision medicine, and an exciting example is DCISionRT®⁵, a predictive test specifically for ductal carcinoma in-situ (DCIS), which will shortly be available in Australia. *In three of the four studies 1. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Effects of radiotherapy and of differences in the extent of surgery for early breast cancer on local recurrence and 15-year survival: an overview of the randomised trials. Lancet 2005;366(9503):2087-2106. 2. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Effect of radiotherapy after breast-conserving surgery on 10-year recurrence and 15-year breast cancer death: meta-analysis of individual patient data for 10 801 women in 17 randomised trials. Lancet 2011;347:1707-16. 3. Hughes K, Schnaper LA, Bellon JR et al. Lumpectomy plus tamoxifen with or without irradiation in women age 70 years or older with early breast cancer: long-term follow-up of CALGB 9343. J Clin Oncol 2013;31(19):2382-7. 4. Early Breast Cancer Trialists’ Collaborative Group (EBCTCG). Effect of radiotherapy after mastectomy and axillary surgery on 10-year recurrence and 20-year breast cancer mortality: meta-analysis of individual patient data for 8135 women in 22 randomised trials. Lancet 2014;383(9935):2127-2135. 5. For more information: https://preludedx.com/ physicians/#predictive-test (accessed 07/04/21).

Our centres Bunbury • Hollywood • Fiona Stanley Hospital Joondalup • Mandurah • Wembley Tel: 1300 977 062 | connection@genesiscare.com genesiscare.com MEDICAL FORUM | WOMEN ’S HEALTH

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Let’s make COVID count for WA women Obstetrician Michael Gannon argues the State Government needs to get it right when it comes to the new women and babies’ hospital. The COVID-19 pandemic has had a disastrous impact on Planet Earth. One of the many benefits of living in the ‘Perth bubble’ during the COVID-19 pandemic has been the opportunity to observe with sheer fascination (and horror) the winners and losers of the pandemic and its massive disruption on society.

This opportunity must not be squandered. The hundreds of millions of dollars pouring into Treasurer McGowan’s purse, from sources as diverse as iron ore royalties, stamp duty and sales tax, must be used to develop a ‘once in two generation opportunity’ to improve the health of women and their newborns.

Many of us with loved ones overseas have been denied the opportunity to see them or care for them. The hard border closures, the subsequent restrictions on travel, and the permanent threat of yet another snap lockdown have prevented interstate travel for leisure, family reunion and commerce. However, it is undeniable that there have been individuals and industries in this state that have benefited greatly.

As AMA WA President, I was critical of the Barnett Government’s failure to ‘future proof’ the new Perth Children’s Hospital by not constructing two extra floors to allow for population growth. The commissioning of both PCH and Fiona Stanley Hospital were mismanaged. We must work together to harness the State’s investment to deliver a purpose-built facility.

Former treasurer Ben Wyatt’s 2019 Budget included a $3.3 million allowance to begin the move of our tertiary women’s hospital to the QEII Campus. Those monies disappeared very quickly and were quarantined as part of the State’s COVID response. Both official and unofficial communications with members of the McGowan Government suggested that the plans for a new women’s hospital had been shelved. Imagine the delight to those of us working in women’s health when we saw the proposal to spend $1.8 billion announced late last year. 10 | MAY 2021

The new women’s hospital must continue to serve as a beacon for excellence in women’s health and there must not be any diminution of unique services such as the Sexual Assault Referral Centre (SARC) with the move to an already busy tertiary hospital campus. Gynaecology must not ‘disappear’ as a small surgical speciality within a general hospital. While gynaecological and obstetric practice are increasingly devolved, there is an important intersection in service, training and patient care. Gynaecological oncologists and urogynaecologists have an important role in supporting both the delivery of maternity services and general gynaecological care.

The responsibility of training the next generation of GP obstetricians and specialist obstetricians and gynaecologists must not be forgotten. We must also build on our research and innovation capacity. Perhaps most importantly, the move presents an opportunity to improve the quality and safety of maternity services available to WA women with onsite access to potentially lifesaving services such as interventional radiology and uterine artery embolisation for massive post-partum haemorrhage, and an intensive care unit. COVID-19 has destroyed lives and livelihoods across the planet. For many of us in WA, these hardships have been an abstract concept. If still alive, Donald Horne would be eager to write a post-script to his 1964 book The Lucky Country. Our success in managing the pandemic owes more to our isolation, the massive distance from the problems elsewhere in the world, our climate and abundant natural resources, not infinite political and bureaucratic wisdom. We must not spurn this unique opportunity to make WA a centre of excellence in the way we look after women and their newborns. ED: Dr Gannon is Head of Department, Obstetrics & Gynaecology, St John of God Subiaco Hospital, a consultant obstetrician in the Perinatal Loss Service of the Women and Newborn Health Service, and President of MDA National. KEMH has been the only tertiary hospital for women since 1916. Work on the new women's and babies hospital at the QEII campus is expected to start in 2023.

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MAY 2021 | 11


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COVER STORY

Breaking the silence More women coming forward to report sexual violence means GPs can expect to be at the frontline, as Cathy O’Leary explains.

It has been a tumultuous time for women’s mental and physical health in Australia in recent months, triggered by a national conversation about sexual violence. Running parallel with the daily news stream on COVID-19 has been a narrative about harm to women, where the alleged perpetrator is not a rogue virus but often a family member, teacher or work colleague. While the catalyst was Australian of the Year Grace Tame, an outspoken advocate for survivors of sexual assault who was groomed and raped by her maths teacher at the age of 15, it has become clear she is no orphan when it comes to sexual violence against women. Thousands of women marched in cities and towns across the country, donned in black, to demand better protection and justice in the wake of serious allegations that rocked Federal Parliament, including the alleged sexual assault of Liberal staffer Brittany Higgins. And while Canberra has been at the epicentre of the storm, experts are urging doctors throughout Australia to be aware that this is a time when current or past traumas can surface among their patients. Symptoms such as depression, insomnia, nightmares and alcohol and drug abuse may turn out to have damaging and sinister origins involving domestic and sexual violence.

continued on Page 14

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MAY 2021 | 13


Breaking the silence continued from Page 13

More seek help WA’s Sexual Assault Referral Centre (SARC) has seen an increase in requests from clients seeking access to its services and says this is largely related to the amount of information recently in the media and on social media. “We frequently see an increase in demand when sexual assault is high profile, and in the news,” a SARC spokesperson told Medical Forum. “Patients with historic sexual trauma seeking counselling services can be triggered and distressed by the public discourse, but we have also seen an increase in people seeking help with recent sexual assault who need access to our acute service. “The conversation makes them more likely to speak up and ask for support.”

SARC says health professionals are also putting their hands up to ask for more support when dealing with patients, with recent requests for training and support from the WA Country Health Service. “We provide a 24/7 telephone consultation service for health professionals seeking advice when seeing a patient with a sexual assault experience,” the spokesperson said. “This service is mostly used by regional WA and WACHS staff, but GPs are also encouraged to access the service. This is especially useful when a patient does not want to attend SARC.” Dr Sean Stevens, who chairs the WA faculty of the RACGP, said he was expecting an increase in presentations to general practitioners around sexual violence. “Whenever these issues feature in the media, we see an increase because it brings up old issues and also alerts patients that

what they’re experiencing is not acceptable,” he said. “I think that’s a good thing because it provides an opportunity for GPs to help in these situations. “But there is no textbook for these sorts of things – there are guidelines and general principles, but every patient is an individual and the way you approach it has to use your previous clinical experience and common sense. “GPs develop a very trusting relationship with long-term patients, and I’ve had occasions when patients disclose something to me that they’ve never disclosed to anyone – not their partner, parents, or best friends, but they feel willing to discuss these sorts of things with their GP. “It highlights just what a privileged position we have as doctors and what an opportunity we have to affect change.” Dr Simon Torvaldsen, chair of the AMA WA’s Council of General Practice, said that while recent events had brought sexual violence to the fore, particularly in Canberra,

SARC resources for doctors How should doctors, particularly GPs, ensure they are as equipped as possible to assist women coming forward for current or historical claims of sexual assault/ sexual violence? Complete the SARC on-line eLearning Package – “Responding to Disclosures of Sexual Assault”. Attend a session conducted by SARC – we usually speak a couple of times a year at the request of the AMA and the RANZGP. We also speak at the YES Doctor forum and Sexual Health Quarters regularly. You can also review the content in the WAPHA Health Pathways Program to be familiar with the processes.

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If women talk to GPs about historical rather than contemporary events, is it still appropriate for them to be referred to SARC? SARC offers a therapeutic counselling service for patients with historical sexual assault/ sex abuse. In order to facilitate a referral to SARC, the client has to call themselves and participate in a telephone triage call. Be aware that there is a long waitlist for these services, so prepare your patient, and be prepared to write them a mental health care plan, to engage privately with community based services. What should doctors advise their patients to do if they are currently

at risk or in danger of more sexual violence? Is this a matter for police rather than SARC? Patients with significant risk of ongoing sexual violence need quite a lot of support. They often need assistance to help them identify safety plans and supportive family/ friends. Encourage them to talk about their concerns and link them to support agencies so that they can make choices about how to address the risk. If they are under the age of 18, a mandatory report to child protection services will be required. For under 16s you can consult with the Child Protection Unit at Perth Children’s Hospital and for over

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COVER STORY abusive relationships and violence have always been a problem. “Some cases are straightforward, others are tricky. The horrible thing is that some of the more severe cases – the out and out violence – are in many respects the easiest from a medical sense because we know exactly what to do,” he said. “If a woman says she was attacked and raped last night, I know the ways to direct her and what needs to be done. But it can be difficult when it’s more nuanced, or there are many shades of grey, and maybe the relationship is not that great but people are not willing to admit it’s abusive. And if you don’t hear the other side of the story, it’s hard to get the full picture.”

GPs at the fore Dr Torvaldsen said it was important that GPs were always alert to the signals that people gave when all was not well, and that they created an environment that made it comfortable for patients to disclose. “That’s why the relationship between the patient and the GP

16s you can call SARC to discuss options but be mindful that our services do not provide safety services. If the risk is from a current or past partner, a referral to domestic violence services may be appropriate. If the risk is imminent, the matter is best managed by the police – the WA Family and Domestic Violence Response Units are a good support and can ensure the patient is linked into other advocacy services, including accommodation and legal services. Are there training/education courses run by SARC that would be beneficial to GPs on a general level, and are there some that

MEDICAL FORUM | WOMEN ’S HEALTH

is so important, because what one of my patients would disclose to me is something they wouldn’t disclose to a stranger,” he said. “But if they don’t walk through my door, I can never help them. And you have to respond appropriately – the initial step is very important. “It’s important that doctors, as leaders in the community and to whom people generally look up, call out certain behaviours and attitudes that are unacceptable. “Every now and then I’ll say to one of my patients “This is bullsh.t … that’s not an acceptable way for you to be treated and let’s call it out for what it is. “Sometimes these people are made to feel it’s their fault, so if their partner is angry and abusive it’s their fault, and that’s made to seem normal. We need to call it out and say that’s not normal.” Dr Stevens said dealing with the victims of sexual violence could be gruelling for GPs and the burden of these types of consults fell disproportionately on female GPs.

involve detailed information i.e. medical and forensics training? SARC offers specific training courses on medical examination and forensic specimen collection for country-based doctors and nurses, however in the metropolitan area, it is advisable for GPs not to undertake forensic examination. It is preferable to refer the patient to SARC. What is the best resource/website for doctors to get information/ contact SARC?

“Women often feel more comfortable talking about these types of issues to female GPs,” he said. “Intimate examinations these days are done overwhelmingly by female GPs, and that is often the time these issues come up. It’s part of what makes a female GP’s job more emotionally draining.” Dr Stevens said GPs had seen a lot more cases of domestic violence during COVID, particularly around the time of lockdowns – not so much during them, but after. “And what we know is that the people who come in and talk about sexual abuse and domestic violence are just the tip of the iceberg,” he said. “The vast majority will not talk about it, and will not volunteer it, so the way you broach it is very important and has to be done in very sensitive way.”

Keeping it simple Associate Professor Laura Tarzia, deputy lead of the Sexual Abuse and Family ViolencE (SAFE) program at the University of Melbourne, says most GPs have the necessary skills to deal with cases of violence against women but lack confidence or assume that some continued on Page 17

Check out our new publications on the home page – Care Packages for Survivors, and Supporters Guides for Family members. The eLearning Package is also on this site. For more specific information on dealing with client presentations, guidelines for practice and education and other resources: https://www.kemh.health.wa.gov. au/Our-services/Service-directory/ SARC/For-Professionals

https://www.kemh.health.wa.gov. au/our-services/service-directory/ sarc

MAY 2021 | 15


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Breaking the silence continued from Page 15 kind of specialised training is required in order to be effective. “There is certainly a role for specialised support in the context of sexual violence, however, often what is needed is quite simple. An empathetic tone, caring manner, and nonjudgmental approach is sometimes all that is required,” she told Medical Forum. “Some women may just want someone to talk through their feelings with, while others can benefit from practical assistance such as referrals for co-occurring issues such as chronic pain, sexual health issues, and mental health symptoms.” Women were more likely to disclose experiences of sexual or domestic violence when they felt supported, cared for, understood and not judged. She said GPs should be proactive when seeing patients whom they suspected might have a history of sexual violence, or who presented

with otherwise unexplained mental health symptoms. “Saying something like: ‘Sometimes difficult experiences in the past can affect how you feel now, and for example, I often see women who have had an unwanted sexual experience in the past that is still affecting them today. Do you think that might be the case for you?’ “It’s important not to be pushy, but rather for the GP to let the patient know that this is an issue they see often, that it is nothing to be ashamed of, and that they are comfortable and safe to speak with if the woman wishes.” Prof Tarzia said recent events in Federal Parliament might have made it easier for women to come forward to report historical sexual abuse, but it might be more that women were no longer prepared to keep silent about their experiences.

in disclosure and help-seeking because of that,” she said. Professor Tarzia said she was a little cynical about what would actually change once the momentum died away. “I would like to hope that at the very least the reporting of recent events has raised more awareness about sexual violence amongst the community,” she said. “But I am concerned that it still plays into the idea of sexual violence/harassment as something that happens in the public arena, whereas statistically women are far more likely to be sexually assaulted by their intimate partners or someone else close to them. “It’s very important that GPs and others supporting women are aware of that also.”

Read this story on mforum.com.au

“I think there is a groundswell of rage and frustration, and the media attention on the issue may remind or trigger many women who have had a historical experience and there may be an increase

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Rural Health West and WA Country Health Service congratulate all finalists and winners of the Long Service and Excellence Awards

LONG SERVICE AWARDS Congratulations and thank you to the following Long Service Awards recipients for their commitment to providing 40, 30 and 20 years of health services to rural Western Australian communities.

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Dr Peter Beaton Dr Walter Byrne Dr Mary Collins Dr Ronald Jewell Dr David Mildenhall Dr Kim Pedlow Dr Michael Peterkin Dr Frederik Pretorius Dr Philip Reid Dr John Robinson Dr Darcy Smith Dr Allan Walley Dr Neil Worthley

30 YEARS

Dr Bernard Chapman Dr William Chow Dr Stephen Cohen Dr John Collis Dr Graeme Findlay Dr Mostyn Hamdorf Dr Simon Hemsley Dr Douglas McCarthy Dr Megan McCormack 18 | MAY 2021

Dr Michael Munroe Dr Philip Smith Dr Richard Spencer Dr Stephanie Spencer Dr Peter Terren Dr Andrew Van Ballegooyen Dr Ann Ward

20 YEARS Dr Stuart Adamson Dr Stephen Arthur Professor David Atkinson Dr Kornelis Bakker Dr Raymond Borcherds Dr Eileen Bristol Dr Reginald Bullen Dr Pamela Burgar Dr Allen Chong Dr Caleb Chow Dr Neil Cock Dr Annette Cransberg Dr Brian Cunningham Dr Jacobus de Bruyn Dr Coert Erasmus Dr Timothy Hadlow

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Dr David Hailes Dr Alasdair Jackson Dr Murray James-Wallace Dr Toby Leach Dr Louise Marsh Dr Nina McLellan Dr Steven Mellett Dr Nazmi Mikhaiel Dr Mark Mottershead Dr Vafa Naderi Dr Angela O’Connell Dr Christopher Plint Dr Amirthalingam Prathalingam Dr James Quirke Dr Marian Rae Dr Gavin Riches Dr Victor Seah Dr Willie Smit Dr Karl Staer Dr Harry Stock Dr David Tadj Dr Rodger Todd Dr Stephanus Venter Dr Heather Wilkinson Dr Joanne Willison Dr Peter Wutchak MEDICAL FORUM | WOMEN ’S HEALTH


EXCELLENCE AWARDS WA Country Health Service Intern of the Year

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A miracle in the making The current COVID-19 vaccines are no overnight sensation – they have been years in the making.

Dr Karl Gruber (PhD) reports

Despite a popular perception that COVID-19 vaccines were rushed through, in reality, they have been in a long-planned and carefully designed pipeline. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a human pathogenic coronavirus of zoonotic origin and was first reported in late December 2019 in Wuhan, Hubei province, China. The virus is the causative agent of the coronavirus disease 2019 (COVID-19), which claimed its first life in March 2020. A few months later, COVID-19 went global and proved to be one of the worst pandemics the world has faced in recent decades. Today, more than 136 million people have been infected with the virus and nearly 3 million have died from the disease. The economic impact of the disease is enormous and continues to grow. 20 | MAY 2021

In the midst of the panic, fear, disease and death that COVID-19 is causing in many parts of the world, we have learned a lot about ourselves, our health care systems, our governments and our research capabilities. One positive and perhaps the most amazing outcome of the pandemic has been the development of vaccines. Traditionally taking up to 10 years or more to develop, COVID-19 vaccines have been designed, tested and deployed within 12 months. Today, 184 vaccine candidates are in pre-clinical development, nearly 100 are currently being tested in phase I, II or III clinical trials, and five vaccines are now widely available and being deployed worldwide. More than 754 million vaccines have been administered already and millions more are on the way. MEDICAL FORUM | WOMEN ’S HEALTH


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FEATURE The COVID-19 vaccine development process has been hailed as “a miracle of modern technology”, but in the minds of many, a lurking fear grows – that these vaccines were rushed into being, potentially sacrificing the safety of their users. However, experts in vaccine development explain that nothing is further from the truth and while they have been made at an unprecedented pace, it hasn’t been at the expense of safety or efficacy. Here is how it was done.

A not-so-new virus The COVID-19 virus is not an entirely new coronavirus – it has known relatives. In the past 10 years, two well-known coronaviruses made the jump from their animal host (bats, most likely) into humans. Severe acute respiratory syndrome (SARS) was first reported in the Guangdong province of China in 2002. The virus infected over 8,000 people across 29 countries, killing about 15% of those affected – an unusually high fatality rate. Ten years later, in April 2012, we saw the emergence of the Middle East Respiratory Syndrome (MERS) coronavirus in Jordan. Since then, a total of 2574 laboratory-confirmed cases including 885 associated deaths have been reported globally with a staggering 34.4% fatality rate. MERS infections have continued to appear sporadically – the most recent laboratoryconfirmed patients were reported in March 2020. Coronaviruses are not the only viruses causing havoc among humans. Viruses such as Ebola, Marburg, Hendra, Nipah, or those causing influenza, have also led to significant morbidity and mortality around the world. But an important outcome of these viral outbreaks has been their role as a warning agent. The clear risks and potential consequences of these zoonotic outbreaks made a mark on the mind of scientists as well as policy makers, who were shaken by the prospect of another, worse, global pandemic. As a consequence, the Coalition for Epidemic Preparedness and Innovation or CEPI was founded five years ago.

MEDICAL FORUM | WOMEN ’S HEALTH

Why CEPI matters CEPI is a global partnership that brings together funding from public, private, philanthropic and civil society organisations. Their goal is to finance independent research projects that develop vaccines against emerging infectious diseases. It is backed by heavy players such as the Bill & Melinda Gates Foundation, the Wellcome Trust and the World Economic Forum. By June 2020, it announced raising more than $1.3 billion to support their COVID-19 efforts. One of the first outputs of CEPI was to fund vaccine research programs against viruses such as MERS, Nipha, Chikungunya, Rift Valley fever and SARS-CoV-2. Since early 2018, CEPI has provided more than $200 million to fund vaccine development against Lassa fever/ MERS-CoV. Critically, it also provided more than $50 million for the development of new technologies in vaccine design. When COVID-19 came along, CEPI jumped into action. “CEPI had effectively a competition. The competition was to come up with a vaccine technology platform that could develop a vaccine to a new virus within 16 weeks,” said Dr Norman Swan, host of the Coronacast podcast and the ABC Health Report. Throughout 2020, five research groups received funding to develop vaccines against COVID-19. By June 2020, Clover Biopharmaceuticals had begun Phase I clinical trials in Perth to test the safety and immunogenicity of a proteinbased vaccine candidate. This was the fifth CEPI-funded vaccine candidate reaching clinical trial testing. CEPI has contributed to vaccines developed by Moderna Inc., Novavax Inc., University of Oxford and AstraZeneca, and Inovio, which had all started clinical trials by this time.

Trials under trial? An important lesson from the COVID-19 vaccine development concerns the traditional pathway of clinical trials, which normally take 10 years or more before a drug can reach patients. In a recent article for The Conversation, Mark Toshner, Director of Translational Biomedical Research at the University of

Cambridge, explained what this actually meant. “I submit grants, have them rejected, resubmit them, wait for review, resubmit them somewhere else, sometimes in a loop of doom. When I am lucky enough to get trials funded, I then spend months on submitting to ethics boards. I wait for regulators, deal with personnel changes at the drugs company and a ‘change of focus’ away from my trials and, eventually, if I am very lucky, I spend time setting up trials: finding sites, training sites, panicking because recruitment is poor, finding more sites. I then usually have more regulatory issues and, finally, if my big pot of luck is not used up, I might have a viable therapy – or not. At this point, it might get delayed because of questions over profitability or any number of other obstacles,” he wrote. So, whenever someone says 10 years consider … “It’s not 10 years because that is safe, it’s 10 hard years of battling indifference, commercial imperatives, luck and red tape. It represents barriers in the process that we have now proved are ‘easy’ to overcome. You just need unlimited cash, some clever and highly motivated people, all the world’s trial infrastructure, an almost unlimited pool of altruistic, wonderful trial volunteers and some sensible regulators,” Dr Toshner said. So, what were the COVID-19 vaccine trials like? Unprecedented may be a good word, streamlined another. “Trials were designed such that clinical phases are overlapping, and trial starts are staggered with initial phase I/II trials followed by rapid progression to phase III trials after interim analysis of the phase I/II data,” said Florian Krammer, an immunologist at the Icahn School of Medicine at Mount Sinai in New York, in a recent review in the journal Nature. Despite being streamlined, these clinical trials were also safe. “All trials have been through the correct phases or process of any normal drug or vaccine. Hundreds of thousands of the very best of us volunteered and had an experimental vaccine. The world continued on Page 23

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FEATURE

A miracle in the making having problems in the long-term. So, this whole thing about a rush is a mirage,” Dr Swan said.

continued from Page 21 watched so closely that when a single person fell ill, we were all debating it,” Dr Toshner explained.

Perhaps a more worrisome question is how fast, efficiently and fair is the distribution of COVID-19 vaccines. So far, only one country, Israel, has vaccinated more than 50% of their population, while most countries have significantly lower vaccination levels.

A key factor that played in favour of the COVID-19 vaccine was the availability of willing patients. For most drugs, recruiting enough patients for clinical trials is challenging. In the case of vaccines, for example, sometimes it takes years to recruit enough patients for a phase III clinical trial, the last milestone before going public. But not so with the COVID-19 vaccine. “Because there were millions of people with COVID-19, they were able to recruit 40,000 people for each trial incredibly quickly, and because there was so much virus around, they got infected very quickly,” Dr Swan said. Normally, for vaccine trials focused on a viral agent, scientists need to wait for patients to randomly become infected by the virus so that they can then test the vaccine. “That's simply a waiting game. We didn't have to wait. People, unfortunately and tragically, were there and they got infected incredibly quickly and you got a result very quickly,” Dr Swan said.

Unprecedented approvals The last step in the development of vaccines is regulatory approval for public use. This usually takes 1-2 years and only then can vaccines start global production. COVID-19

vaccines were approved within 1-2 months. An important factor of their approval was that they had been tested in millions of people with no significant safety concern. “At least in the Australian context, tens of millions had already had (COVID-19 vaccines) in the real world with no new safety signals emerging,” Dr Swan explains. “So, in terms of safety and effectiveness, thanks to the Israeli data and the British data, we are confident that they work in the real world and that they are not dangerous, at least in the short to medium-term.” The only aspect of the COVID-19 vaccines that remains to be seen is the long-term safety as there just hasn’t been enough time elapsed.

As of 9 April 2021, the Australian Department of Health reported that 1,138,866 doses of COVID-19 vaccines had been given – or about 4.5% of the total population. At the time of writing this article, the Australian government had backed down from their vaccination targets due to multiple issues with distribution and administration of vaccines, and with the growing issues surrounding the safety of the AstraZeneca vaccine, which is now not recommended for those under the age of 50. Another problem is equity. Rich countries are being accused of hoarding vaccines, while poor countries are struggling to get enough doses to vaccinate their frontline health workers. Only time will tell how Australia and other countries will move forward with vaccination efforts, but clearly more work is needed to address all the issues at hand.

“However, there is a very good track record in vaccines of not

Traditional development Design and exploratory preclinical studies (years)

Process development preclinical, toxicology studies (2-4 years)

IND submitted

Clinical trials (5-7 years total) Phase I

Phase II

Phase III

(1-2 years)

(2 years)

(2-3 years)

BLA submitted

Regulatory review by FDA, EMA etc (1-2 years)

Large-scale production and distribution

15 years or longer

SARS-CoV-2 vaccine development

Clinical trials (months) IND submitted

Design and exploratory preclinical studies (months)

Process development preclinical, toxicology studies (months)

Phase III

BLA submitted Regulatory review by FDA, EMA etc (1-2 months)

Phase I Phase II Production (at risk)

Pre-existing from SARS-CoV and MERS-CoV

Partially pre-existing and parallel development

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Overlapping clinical process

10 months to 1.5 years total Review on a rolling basis

MAY 2021 | 23


FEATURE

GPs and pharmacists …collaborators or competitors?

Pharmacists are increasingly being consulted for advice on a range of minor health conditions – it’s free, they are everywhere, and you get a quick opinion and “something to make you feel better”. Now, there is a new push to expand the so-called scope of practice among pharmacists to allow them to offer medical advice and medication for more than mild conditions. Can pharmacists really do some of the tasks traditionally done by GPs? Should they? Will they? A key argument why some pharmacists are pushing for their involvement into GP territory is logical because according to a 2019 report from Deloitte Access Economics, there will be serious shortages of GPs by 2030. The General Practitioner Workforce Report 2019 aimed to determine if there would be an under or oversupply of GPs in Australia over the next few years. “Both urban and regional areas will become progressively 24 | MAY 2021

undersupplied over the 10 years to 2030, resulting in a deficit of 9,298 full-time GPs or 24.7% of the GP workforce by 2030,” the report said. “The deficit is expected to more pronounced in urban areas (31.7%) compared to regional areas (12.7%).”

affecting GP and emergency departments in Australia. High outof-pocket costs, long waiting times, poor access to after-hours care and lack of enough GPs in rural and remote areas are some of the problems often associated with the Australian health care system.

Following the publication of this report, the Pharmacy Guild of Australia issued various statements arguing the need for pharmacists to step in and help with the work of GPs. For example, in a statement for the Australian Journal of Pharmacy, George Tambassis, the national president of the Pharmacy Guild, said:

According to a campaign from the Pharmacy Guild, pharmacists may be able to help with all these problems. According to the campaign, called “Community Pharmacies: Part of the Solution”, pharmacists can “administer basic healthcare services to drive down costs to patients and the health budget, reduce waiting times and increase frontline health accessibility.”

Adjunct to care “Empowering pharmacists to take on a greater role in the healthcare system by doing things like giving more vaccinations, issuing repeat prescriptions for things like blood pressure and treating common ailments like asthma and migraine would relieve some of the pressure on already overworked GPs.” There are also other issues

Today, pharmacists are already doing some of the work traditionally reserved for GPs, such as triaging. “Pharmacists currently triage patients for minor ailments and medicine safety problems. Such initiatives will facilitate further interprofessional collaboration MEDICAL FORUM | WOMEN ’S HEALTH

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The push for pharmacists to take on more primary care tasks has created tension but is it a solution to problems with health care delivery? Dr Karl Gruber asks the question.


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FEATURE

between doctors and pharmacists. Teambased care will provide the best outcomes for patients,” Dr Tin Fei Sim, president of the WA branch of the Pharmaceutical Society of Australia, told Medical Forum. Perhaps the best example of a good use of a pharmacist’s skills can be found in Australia’s efforts to vaccinate millions of people as soon as possible in the midst of the COVID-19 pandemic. Early this year, the Australian government announced their plans to allow community pharmacies to dispense COVID-19 vaccines to the community. The vaccine will be administered by specially trained registered pharmacists, as well as nurse practitioners, nurses and Aboriginal Health Workers under the supervision of an approved pharmacist. “Including pharmacists in the national rollout is in the public MEDICAL FORUM | WOMEN ’S HEALTH

interest, to increase public access to vaccines quickly while increasing vaccination rates and pharmacists stand ready, willing and able to deliver COVID vaccinations to the Australian community,” said Associate Professor Chris Freeman, president of the Pharmaceutical Society of Australia. However, not everyone is on board with the idea. According to Dr Mark Morgan, GP and Professor of General Practice at Bond University, the roles of pharmacist and GP would work best in collaboration rather than competition. “GPs and pharmacists work best together when each are using their unique skills and knowledge,” he told Medical Forum.

In terms of the tasks performed by GPs, Dr Morgan explained that GPs were experts when it came to assessing and managing undifferentiated presentations. “We can manage uncertainty, organise tests, arrange follow up and set up safety net arrangements. GPs can often access detailed past medical history and results from investigations to help make the best plans with our patients. GPs help patients by explaining and facilitating non-drug interventions,” Dr Morgan said. “Minor illness presentations to GPs provide the venue for opportunistic preventative checks. They provide a time when lifestyle interventions such as smoking cession can be progressed.” continued on Page 26

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GPs and pharmacists continued from Page 25 Would pharmacists be able to fulfil all these tasks? For some the answer is simply no. One of the most ardent opponents to the “pharmacist as GPs” model was the late RACGP President Dr Harry Nespolon who argued that pharmacists were not able fulfil the role of GPs as they lacked the necessary training, experience and expertise. Some statements made by Dr Nespolon on this topic included:

Vocal critic “‘Empowering’ pharmacists to treat serious diseases like asthma is a recipe for disaster as we have discovered in places like the UK, where there is an increasing number of serious incidents, including deaths, due to unsafe practice. The fact that there is a shortage of GPs does not change the skill levels of pharmacists –

Finally, having pharmacists work as GPs may lead to fragmentation or even duplication of service, Dr Morgan says. “…patients receive overlapping care from multiple providers with inadequate exchange of information, which is associated with increased costs and poorer outcomes.”

patient care is more effectively and safely delivered within general practice.” Other issues pinpointed by Dr Morgan is that a GP office offers a confidential environment with all the necessary diagnostic equipment at hand. This would not be possible at the nearest pharmacy.

The way forward

But a more important point concerns the medications patients receive at a pharmacy. “A significant proportion of people with self-limiting minor illnesses are sold over-the-counter medications. The evidence supporting many of these medications, such as cough mixtures for use in children, is nonexistent,” Dr Morgan told Medical Forum.

The government has not yet made its final decision. The rollout of COVID-19 vaccines would be aided with help from pharmacists, but more work is needed to reach a consensus on the best way forward. One potential model could involve an association between pharmacists and GPs, Dr Morgan said.

“Many community pharmacies create confusion and reduce health literacy by selling low value and unnecessary supplements and remedies. Many walls are lined with products that have more to do with profit than clinical benefits,” he added.

“Imagine a world where pharmacists were funded to work in general practice engaged in medication governance and patient education as part of the team. Imagine the same world where

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FEATURE immediately necessary medicines were dispensed direct from general practice while longer term medications were distributed direct from warehouses,” he said. Collaboration is also in the mind of Dr Sim, who says that true collaboration between pharmacists and GPs is the key. “When GPs and pharmacists work together collaboratively and putting patients’ health and wellbeing at the centre of focus, this is the best outcome. Ultimately, we need to work together to achieve the most cost-effective delivery of healthcare for all Australians,” Dr Sim said. Another argument being pursued is a role for pharmacists in addressing ED overcrowding and long waiting times. “People attend ED for a variety of reasons including deep concern that their condition needs rapid attention with timely investigations and treatment. Hospitals are often regarded as a place of safety and expertise. I think it is naïve to use economic arguments that patients can be sent away at the front

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door of ED to see a community pharmacist for equivalent treatment,” Dr Morgan said.

False economy “The amount of assessment and triage needed to set this up in a way that is both acceptable to the community and safe for patients would amount to doing most of the consultation – making for very few savings if any,” Dr Morgan explains. Pharmacists, as currently trained, are experts in medication use, not in diagnosis or multimodal management. So, what is the solution then? According to Dr Morgan, bigger investments in GP clinics may be the way to go. “Examples include allowing practice nurses to work to full scope of practice with Medicare patient rebates, infrastructure and IT supports, increased patient rebates generally, CME allowances, slick systems with minimised red tape, streamlined referral systems to the wider team and subspecialties, shared care arrangements for complex and subspecialist care etc,” Dr Morgan said.

to expand their scope of practice is also backed by Dr Christopher Harrison, Research Fellow of the School of Public Health at the University of Sydney. “There have been several initiatives to increase the scope of practice of other health professionals (such as practice nurses) to help address health workforce shortages. These have been successful because the practice nurses are a part of the health team,” Dr Harrison told Medical Forum. Whether empowering nurses or pharmacists, the bottom line is that more research is needed to ensure that, at the end of the day, patients are the ones receiving a benefit. “I think before any change is made, it should be considered whether this change will foster team-based or collaborative care of the patient. In a time when multimorbidity is increasing, the last thing we need is further fragmentation of care,” Dr Harrison added.

The idea of empowering nurses

MAY 2021 | 27


Breast researchers look to genes Local breast cancer research is forging ahead using genetic clues to tackle the disease, as Cathy O’Leary reports.

Professor Christobel Saunders

After eight years of chipping away, a team of Perth researchers has made a genetic breakthrough that could help treat a deadly rogue form of breast cancer. And a few kilometres away, St John of God Subiaco Hospital has become the first private facility in WA to take part in a groundbreaking international clinical trial aimed at preventing breast cancer in women who have the hereditary BRCA1 gene. Together, their work paves the way for a better understanding of how to prevent, detect and treat the cancer that now affects a staggering one in seven Australian women by the age of 85. 28 | MAY 2021

A team led by Associate Professor Pilar Blancafort from the Harry Perkins Institute of Medical Research and the University of Western Australia has discovered a cancer-causing gene and protein for a particularly aggressive and lethal breast cancer. They found the cancer gene is typically resistant to treatment, protecting the tumour by producing large amounts of a unique protein which triggers tumour growth in a sub-group of hormone-sensitive breast cancers. Standard hormone treatments are unable to kill the tumour cells and may promote tumour growth and worsen survival in patients.

The research, published recently in Nature Communications, investigated hormone sensitive breast cancers, which make up about three quarters of all breast cancers and typically have a high survival rate. The team found a previously uncharacterised group of hormonesensitive cancers which are very aggressive.

Hormone spotlight A/Professor Blancafort, who heads cancer epigenetics at Perkins, said hormone-sensitive breast cancers usually had better outcomes than hormone-resistant ones such as triple negative breast cancer. MEDICAL FORUM | WOMEN ’S HEALTH

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RESEARCH “However, a small percentage of patients experience a very aggressive cancer that results in the worst outcomes of all breast cancers, with half of all women dying from the disease,” she said. “When we look at these cancers, we find that they are bigger, tend to spread more commonly to lymph nodes, and have a higher death rate. What we needed was to find a way to identify them and then to treat them.” They began by taking data from a major study in the US that looked at thousands of breast cancers.

“As a result, this cancer protein can protect the tumour cells against anti-cancer hormone treatments, preventing the cancers from being cured,” she said.

Limiting growth “The cancer-promoting function of AAMDC acts as a ‘survival kit’, allowing tumours to adapt to these conditions, supporting the growth and multiplication of breast cancer cells in conditions of metabolic stress.” New drugs, which blocked the AAMDC pathways activated to

It is estimated that at least one in 400 women in the developed world has BRCA1. Over the course of a lifetime, women carrying the gene have a 70% risk of developing breast cancer and a 40% risk of developing ovarian cancer. While regular breast cancer screening can help in early detection, there are currently limited preventative treatment options available. Consequently, many women opt to have both healthy breasts surgically removed to protect themselves. The five-year trial is being coordinated in Australia by Breast Cancer Trials and led by the Austrian Breast and Colorectal Cancer Study Group. Collectively, the international trial will recruit almost 3000 women from seven countries, including about 300 women from Australia. While SJG Subiaco is the only private hospital in WA recruiting, eligible patients from other facilities can participate.

New treatments Prof Saunders said the BRCA-P trial was a world-first, aiming to prevent breast cancer from occurring without surgical intervention in those at highest risk. “Women with the BRCA1 gene have a significantly higher chance of developing breast cancer and are also more likely to develop cancer at a younger age,” she said.

Associate Professor Pilar Blancafort

They picked those hormone-driven cancers with the worst chance of survival and looked carefully at how they were different from cancers with better outcomes.

allow cancer cell survival, meant it might be possible to kill these cancer cells as well as restore their sensitivity to usual hormone treatments.

“By analysing this sub-group, we discovered these aggressive cancers have extra copies of a particular oncogene. The cancer cells use this multiplied gene to make a cancer driving protein (AAMDC) at higher than normal levels,” A/Prof Blancafort said.

“Hopefully this will dramatically improve the poor outcomes these patients currently suffer,” she said.

The protein promoted growth of the cancer but, unusually, it was not controlled by oestrogen and progesterone, the hormones in breast tissue which were typically the major controllers of cell growth. MEDICAL FORUM | WOMEN ’S HEALTH

“Importantly we can now find these cancers by looking for high levels of AAMDC in the tumour cells.” At SJG Subiaco, the BRCA-P trial led by breast surgeon Professor Christobel Saunders will investigate if denosumab, a drug used to treat osteoporosis, is safe and effective in preventing breast cancer in women carrying the BRCA1 gene.

“While a preventative double mastectomy is a highly effective treatment option, surgery itself carries risks, and can be physically and emotionally challenging. “Our hope is that the drug will switch off the BRCA1 cells before they become cancerous, providing an alternate, less invasive preventative option compared to surgery and improve outcomes for women with the BRCA1 gene.” She said that if successful, the trial could redefine how breast cancer was prevented in Australia and across the world.

Read this story on mforum.com.au

MAY 2021 | 29


Medicine can be seriously fun A medical practice in Rockingham combines clinical care with a light heartedness that leaves everyone feeling more positive.

By Ara Jansen

Blame George Clooney. It’s partly his fault that Christabel Samy became a doctor. More precisely you can blame Dr Doug Ross, Clooney’s character from the iconic television show ER. “I grew up watching ER and I always wanted to be a paediatrician,” says Christabel. “It wasn’t until I went into training that I decided to become a GP because that way I got to help families through the highs and lows.” When she was eight, Christabel suffered facial burns and for the next two years spent a lot of time in outpatient therapy. All the time in hospital and being around doctors helped her decide that medicine was the career for her. 30 | MAY 2021

Around the same time, the movie Patch Adams was released. Starring the late Robin Williams, it’s about a real-life doctor who treats patients with humour. While his patients loved it, the medical community wasn’t laughing. Christabel always wanted to make sure her own practice would be a place where laughter is medicine and a positive atmosphere does everyone good. After finishing a medical degree in York in the UK and working in the NHS, Christabel now injects plenty of energy and passion into the practice she started in Rockingham four years ago. Earlier this year she opened a second practice in Canning Vale. She’s easy-going, loves to work, is a self-confessed chatterbox and can

often be seen in colourful towering heels. The latter being a regular source of discussion amongst patients and the odd bet about what colour Christabel will choose.

A family affair Christabel, 32, coaxed her parents out of retirement to help create the Samy Medical Group. “I’m an only child and close to my parents because we moved around a lot. They were always a constant, even as I moved schools and explored new countries.” Her mum Matilda is a retired special needs teacher. She’s the practice manager and her dad is affectionately known as Prof Samy and as a former accountant is the business manager. MEDICAL FORUM | WOMEN ’S HEALTH

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sit on a pedestal and don’t really get to know their patients. A lot of our consultations have a mental health component. When you make yourself approachable and your patient is telling you about their fears, you want to make sure you hear them and they know you hear them. You can’t expect someone to tell you something deeply personal in a 10 or 15-minute appointment if you haven’t built a rapport with them. “Patients often say they feel so much better and that they felt like they were chatting to a friend. It’s hard to get that in a standard consultation.” It’s one reason that social media has worked so well for the practice because it helps the patients get to know the professionals they’ll be seeing. It also shows them as human and as people who struggle with keeping away from chocolate, doing more regular exercise or simply being very average dancers.

“My father raised me with an ethos of social responsibility. He’s a very affable character, a good inspiration and deeply knowledgeable,” says Christabel. “He’s so positive about us doing our part to give back to the community and I think people respect that.” Inspired and influenced by her father’s lifelong work in corporate and social responsibility as well as her own experience in the NHS, the practice bulk bills and has established a trusted network of allied health services to refer patients to which they refer patients. There’s no point in sending a patient somewhere if they can’t afford the sessions, so Christabel says they work with patients to help them find affordable options. After working in the NHS, Christabel says it was a challenge to go from only thinking about a patient and their medical needs in a free system to treating a patient and having to take cost into consideration. “It is a challenge and I really have to think about someone’s financial situation while delivering MEDICAL FORUM | WOMEN ’S HEALTH

quality care. Will they have to wait long because they can’t afford something and will that be a limiting factor. Patients are not always good at saying ‘I can’t afford that’. “We want to offer quality clinical care, which is affordable, and that’s bulk billing. I wanted to make sure we were holistic and working with others to provide that care to the community, while having fun.” Adamant about never taking away from the seriousness of practising medicine, Christabel has equally been determined to make the surgery a place filled with positive energy, enthusiasm and when needed, a good dose of fun.

Social media fun Follow them on social media and you’ll meet the doctors, Prof Samy and various other staff as they dole out relevant health information, some personal hints and tips and the Friday dance-off. “It’s a young and vibrant practice,” she says. Her philosophy is built on two words – engagement and empowerment. “Gone are the days when doctors

“We get a lot of patients who have found out about us through social media. I think we come across as really approachable. The people who spend the most time on our social media are aged between 40 and 70, even though you would assume it to be younger than that. We’re finding patients are a lot more tech savvy too – they bring in their iPads to make notes. “I really believe that technology can be used to enhance health care and delivery.

Info sharing “If there’s a big public health announcement, our patients know we’ll post about it. Sometimes the information is serious and sometimes it’s fun and can be anything from a vaccine that has come out to a new app for health hygiene. This way people can access high quality information and contribute to the discussion if they want to. “If we post about something like a heart check, we definitely see an increase in patient engagement.” As a newer doctor on the block, Christabel also wanted to help the older people in the community retain a sense of connection. Inspired by one of her patients who lost her husband after 60 years of marriage and retired into her shell, continued on Page 33

MAY 2021 | 31


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• Eating Disorder Management – patient vulnerability issues and binge eating disorders through COVID.

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Medicine can be seriously fun continued from Page 31

Dr Christabel Samy with her parents

Christabel established a monthly morning tea. It has been a huge local hit. Whether or not you’re a patient, anyone living locally and aged over 50 is invited to attend. “What I really want is for people to have enough knowledge about how to keep themselves healthy. That way we can start a conversation. Which is why every two weeks we also have a health seminar, which is free to anyone who comes to the practice.” Filled with general but targeted information, they are designed to educate and open the door to bigger and wider conversations to encourage people to be proactive about their health.

Empower not bully “We want to empower them to be healthy and stay healthy. If you want to help improve someone’s health, you can’t just bully them into it. You want to find out what someone’s struggles are, what the psychosocial issues are. I try and see it as a partnership and I find this approach tends to produce better results.

achieve that by themselves. If you come up with more practical ways of getting to know them, then you can find common ground, like if you both find it hard to get to the gym. I’m sharing some real life experience and that helps us come up with practical goals and the little things which can affect change in the long run. That’s a powerful mindset to help cultivate.”

“I think people want to be healthy and I don’t think they can always

Christabel says fun, a positive atmosphere and a dose of humour

tempers work and acts as a pressure release valve when things get grave, especially on a day that can go from delivering bad news to dealing with mental illness and then a debilitating illness. “We work hard and seriously, but a fun video on social media is a break, sometimes a catharsis, a destress and something light-hearted, which I think is important when you work in this profession.”

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MAY 2021 | 33


Q&A with... Hannah Pierce, president of the WA branch of the Public Health Association Labor had a resounding win in the State election, but public health advocates argue more needs to be done to keep us healthy, and COVID is not the only threat.

MF: It is tempting for governments to throw all their resources at quashing COVID-19. How important is it to not let public health issues become crowded out by the pandemic noise? HP: The COVID-19 pandemic has put the importance of public health in the spotlight, and in particular the Australian public health response has highlighted the importance of prevention. We now need governments to apply the same level of dedication they’ve used to prevent the spread of COVID-19 in Australia to all the other health issues. Cancer, sexually transmitted infections, mental health challenges, the health impacts of climate change – all this and more existed pre-pandemic, and it continues to burden our communities. MF: The State Government has committed to increasing investment in disease prevention, including increasing investment to at least 5 per cent of the total budget by 2029. Why is this important, and will it be enough? HP: The WA health and mental health systems face enormous financial pressures and a growing disease burden associated with increased chronic disease and mental health challenges, an ageing population, and widening health inequities. It’s just not feasible or sustainable to keep spending more and more public funds on acute and emergency-based services without also investing in the other end of the spectrum. We need to ensure that we achieve a balance of investment across service types, and this means investing more in prevention, which is desperately underfunded in WA. This will help to keep people well in their communities and out of hospitals in the first place. Five per cent would be an excellent target to reach – the challenge is getting there over the next eight years. We want to see benchmark reporting on prevention expenditure start immediately. MF: Are you concerned of a looming “syndemic” caused by rising rates of 34 | MAY 2021

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Q&A non-communicable disease such as heart disease, type 2 diabetes and cancer, and what can be done to turn it around? HP: Organisations like Cancer Council have been raising the alarm about the impact the pandemic has had on cancer diagnoses for example, and there are concerns that more people will die from preventable diseases as they hold back on visiting their doctor. To tackle this, a good starting point for the WA Government would be to implement all of the recommendations from the Sustainable Health Review Final Report, including increased investment in prevention. The answers are right in front of the government – they just need to get moving. MF: What is the role of doctors, particularly GPs, in trying to curb rising rates of lifestyle diseases? Should they be more proactive with their patients, even if they risk being too intrusive? HP: Everyone working in the health system has a role to play in curbing chronic disease, including GPs. But it’s unhelpful for the focus to be purely on individual behavioural change. Policies that create supportive environments to help encourage healthy behaviours, and increased investment in prevention will provide the most benefit. One of the most important things all doctors can do to help generate change at a population level is to support calls for the implementation of evidencebased policies that we know work to address the key risk factors of chronic disease. MF: The State Government hasn’t committed to your call to introduce a minimum unit price for alcohol. Why is this important and doesn’t it risk getting light to moderate drinkers off-side? HP: In WA, alcohol is promoted and sold at dangerously cheap prices. We know there is a strong link between alcohol price, alcohol use, and alcohol-related harm – as the price of alcohol increases, use decreases in the general population and among heavier drinkers. A minimum unit price for alcohol would set a price below which drinks cannot be sold. One of the reasons it is an effective policy is because it is a targeted measure

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that would reduce alcohol use among the heaviest drinkers, while having minimal impact on low-risk drinkers. This is because low-risk drinkers drink fewer drinks overall and buy less cheap alcohol than heavy drinkers. MF: Likewise, would a ban on unhealthy food and drink advertising at state-owned assets really change behaviour, especially in adults? HP: There’s very clear evidence that exposure to food marketing has impacts on children’s nutrition knowledge, preferences, purchase behaviour, consumption patterns and diet-related health. Why are our kids being targeted with junk food ads on their way to school? Advertising works – that’s why junk food companies invest so much in it. It means more sales for them. Obesity-related illnesses are set to cost WA hospitals over $610 million a year by 2026, yet the government is still selling advertising space to the very companies and products that are making us sick. A ban on advertising of unhealthy food and drinks on all state-owned assets would support broader obesity prevention strategies. MF: On a positive, the State Government has committed to maintaining the current restrictions on electronic gaming machines in WA. Why are pokies so bad for public health? HP: West Australians just need to look across the country to see the devastating effect pokies have on the physical, social, and mental health of individuals, families, and communities. These machines are purposefully designed to be highly addictive. Moderate to severe problem gambling results in suicide, relationship breakdown, financial difficulty, mental health problems such as anxiety and depression, and crime. Gambling particularly affects vulnerable groups in the community, such as people from low socioeconomic backgrounds, and often has inter-generational impacts. MF: Climate change remains an inconvenient truth for many politicians. What commitment is needed by governments and why? HP: A healthy WA community is impossible to achieve without a healthy environment. We know that governments really cannot commit

enough to address the impacts of climate change. Action is needed now. While a focus has been on a target of net zero emissions by 2050, to have a real impact this needs to be moved forward to 2040. Luckily in WA we have several key strategic documents released in 2020, including the Climate Health WA Inquiry Final Report, that provide a blueprint for the WA Government to tackle the issue of climate change. These reports highlight there’s a lot the health sector can do to help reduce its own emissions and contribute to designing and implementation adaption plans for the changing climate. MF: Are groups such as Healthway still necessary and why? WA is lucky to have an organisation like Healthway, whose core role is to promote and facilitate good health and activities which encourage healthy lifestyles. Many people are unaware of just how much Healthway does for our state. It not only provides funding to sport, arts and community events and programs to help reduce children’s exposure to unhealthy products, but Healthway’s local investment in prevention research and its focus on translation has resulted in an acceleration of research into practice in WA. MF: The Association of Australian Medical Research Institutes recently warned that a decline in philanthropy and revenue from international students meant fewer medical research careers would be supported? How would this impact public health? HP: The AAMR identified these risks in the context of COVID-19. Public health research and research on preventative approaches is an important part of health research generally; something which the Sustainable Health Review Final Report has picked up, and which requires continued and sustainable investment. It is vital that governments continue to support health and public health research, and that we work to support groups who may be disproportionately affected by the ongoing impacts of COVID-19 and the generation of revenue for research, including women.

MAY 2021 | 35


The misogyny of iron deficiency Low iron is the most common nutrient deficiency in the world and, as Cathy O’Leary reports, women bear the brunt.

Tiredness and brain fog in women can be dismissed as the innocuous casualties of busy lives but Perth researchers are worried iron deficiency is often going under the radar.

can lead to arrhythmia, an enlarged heart or even heart failure.

They argue that many women, including those fit and healthy, are actually anaemic, unaware they have abnormally low levels of red blood cells to carry oxygen around the body.

It’s estimated that 30 per cent of the world’s population is anaemic primarily due to iron deficiency, and women bear the lion’s share because they lose iron during their periods and need more when pregnant or breastfeeding.

The impact can be significant, with added strain placed on the heart because it needs to pump harder to move enough oxygen, and this

In a recent research paper in the journal Anaesthesia, researchers from the University of Western Australia and University College

London highlighted the need to improve diagnosis and treatment of the common condition often overlooked in women. Team lead Professor Toby Richards, Lawrence-Brown Chair in Vascular Surgery at UWA, is calling for greater recognition and equality for women’s health. He said statistics showed one in three women would need to take iron supplements at some point in their life. “Our figures show that up to 18 per cent of women who appear fit and

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Professor Richards’ team surveyed two groups of women, including 68 triathletes and 181 students, at a UWA orientation day. The women completed a simple questionnaire about previous iron status, menstrual blood loss, diet and motherhood. They were then tested for anaemia. Of the 181 women tested, about 15 per cent or one in seven women were anaemic and most were unaware. “This is alarming that so many apparently fit and healthy women are actually anaemic, which may impact on their physical and mental health,” Professor Richards said.

healthy are actually deficient in iron, with heavy menstrual bleeding the most common cause,” he said. “Symptoms reported by women range from fatigue to brain fog, hair loss and eating ice.”

“Issues with a women’s menstrual cycle and particularly heavy periods are surprisingly common and often not recognised with more than half also suffering iron deficiency,” he said. “It’s so common it’s hiding in plain sight and both are underdiagnosed issues in women’s health. Unfortunately, there has been a dogma to accept these as ‘in the normal range’ for women.”

Professor Richards said iron deficiency was a particular problem for women involved in fitness or sport, with up to one in five athletes affected.

He said many women simply coped with constant tiredness among a host of other symptoms, without addressing the root cause. Some were wrongly put on depression medication when in fact their problem was a lack of iron. “We want to raise awareness of these conditions and help women recognise the signs and symptoms, in order to get the treatment that their body needs to improve their health and welfare,” he said.

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orthopaedics paediatric surgery plastic surgery urology vascular surgery

For more information about the centre and to meet our specialists, visit www.sjog.org.au/carine Unit 1, 2 Gemstone Boulevard, Carine

T: (08) 6258 3800

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E: carine@sjog.org.au

MAY 2021 | 37


ChestRad is a medical imaging practice in the Nedlands hospital precinct dedicated solely to cardiac CT and chest imaging Our staff and equipment were handpicked to provide an uncompromised patient experience and diagnosis. We recommend coronary C T to GPs as a first line test for CAD as it is more sensitive and at least as specific as other tests. Our pricing is set to make the test m o r e a v a i l a b l e t h a n e v e r. f a s te r, s a f e r, s i m p l e r, c o s t- e f f e c t i v e

38 | MAY 2021

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MAY 2021 | 39


What surrogacy means for women Nadeen Laljee-Curran explores the minefield of becoming a mother through surrogacy.

Surrogacy remains relatively uncommon in WA, leading to an unclear understanding by many in health services. My own experiences and conversations with Perth mums through surrogacy, shine a light on the need for more understanding and empathy. I am grateful to my GP, who despite time pressures, provided a safe space for me when she had to deliver the likely diagnosis of premature ovarian failure. Whilst it is widely understood that not having children is lifechanging, in my experience not all health professionals realise that for some women, the role of motherhood is intrinsic with womanhood. Studies have shown that many infertile women feel incomplete and become constantly preoccupied with the quest for motherhood. This was certainly me. I was willing to go to any lengths to have a child. Having a kind and empathetic GP made all the difference. I was also lucky because my GP referred me immediately, as she understood there was little time to waste. Unfortunately, the same wasn’t true for Gayle – her GP didn’t know surrogacy was an option. He focused on things for her to try in her pregnancies even though her condition had seen her miscarry once and forced to terminate three pregnancies to save her own life. Perhaps an earlier referral to surrogacy might have saved Gayle and her husband a lot of heartache.

40 | MAY 2021

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GUEST COLUMN Gayle, who had her daughter through surrogacy in Canada, explained that she had suffered so much loss that she had trouble enjoying the good news when her surrogate was eventually pregnant. The women I spoke with all suffered anxiety through the pregnancies and appreciated having GPs who understood how hard it was for us to trust someone else to do what we longed to do. As mothers we have had mixed experiences with health services since having our children. One of the more difficult experiences has been doctors questioning whether it is legal in Australia. Although the difficulty is fragmented and inconsistent laws across Australia, a better understanding of WA’s reproductive technology laws would vastly improve the consumer experience. For children born through surrogacy in Western Australia, there is a legal process whereby the parentage must be transferred from the birth parents to the intended parents – the parents who will love and raise the child. When Rebecca* had a child through a local Perth surrogate she immediately applied for a transfer of parentage but it took nearly 12 months for her son to be legally recognised as hers. Rebecca luckily had a flexible and compassionate GP who understood their experiences and the needs of the child.

(biological but not legal) parents in the interim period. If this had not been the case, it would have been difficult for Rebecca to seek health care for her child. She recounted a time when her regular GP was unavailable and she put off seeing a GP as she was concerned to go to anyone else. A trip to the hospital emergency department was also very distressing as she did not come up as the mother on the state register. "My friend, a mum of two herself, had carried a baby for me for nine months and given birth only weeks earlier, the last thing I wanted to do was ask her to come with us to the GP! She had already given so much,” Rebecca said. The mums I spoke to also shared how comments or questions based on assumptions could be hurtful. They explained that they had encountered doctors who didn’t understand surrogacy and different types of surrogacy. I was recently asked by a doctor trying to understand family medical history, if I knew much about my child’s ‘mother’ given she was donor-conceived. I do know because she is my biological daughter. Surrogacy does not necessarily mean

egg donation and assumptions like this are easy to avoid. There are two types of surrogacy, traditional and gestational. Traditional surrogacy is where the surrogate’s own egg is used, so the resulting child is the surrogate’s biological child. Gestational surrogacy uses the intended mother’s egg, or that of an egg donor, so that the resulting child has no genetic link to the surrogate or gestational carrier. When discussing what we wish all health providers knew about surrogacy, we all agreed: an understanding of the law in WA, the types of surrogacy and accepted terminology. Surrogacy terminology is extremely important; using the wrong terminology has the potential to undermine our desire to be treated like any other mother. Simple adjustments are meaningful and respect all those involved: "surrogate’ rather than ‘surrogate mother’, or worse still ‘mother/ mummy/mum’. While a surrogate is a very special person in the lives of a family, a surrogate is not mum, nor would she want to be. However, I am ‘Mum’ and I have definitely earned that title. ED: *Name has been changed for privacy Nadeen Laljee-Curran is an engagement coordinator at Health Consumers’ Council.

He treated the child supervised by his

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MAY 2021 | 41


Not bound by borders Lack of education and a surge of home DIY could result in more asbestos-related disease, warns campaigner Jo Morris. While COVID-19 rings out around the world, let us not forget ongoing health and safety issues that know no boundaries and continue to affect people in our community every day.

to work for change for the sake of future generations. With the average age of first exposure for WA mesothelioma sufferers being 24, we need to be vigilant to ensure young people, particularly those going into the trades, are empowered to make educated decisions when it comes to working with asbestoscontaining materials.

With the highest recorded rates of mesothelioma in the world and likely to have the most in situ asbestos products of all states, Western Australia has a devastating legacy of asbestos and its impact is far from over. On average, one person dies every 12 hours in Australia from asbestosrelated mesothelioma, and it is estimated there are 4000 deaths a year from the effects of asbestos. The organisation Reflections was established in 2016 to support sufferers and their families, promote research into better treatment outcomes and increase awareness of the risks of exposure, particularly for home renovators and tradespeople. As Reflections’ co-founder and director, I have spent the past five years working in this area to help reduce the ongoing impact of asbestos. My father, Barry Knowles, was diagnosed with mesothelioma in February 2010 and given six to nine months to live. Defying medical odds, he survived seven years and wrote his memoir, Reflections Through Reality, which became a catalyst for establishing a foundation of the same name. Before Dad’s diagnosis, although having lived in WA my whole life and working in the building and construction industry, I knew little about asbestos and had never heard of mesothelioma. It took some practice to even pronounce it. Through my work, both as a building designer and with Reflections, I hear and see all too often the ignorance and lack of awareness around asbestos. Many people believe it is a thing of the past, that we are no longer at risk or that it takes long-term exposure. 42 | MAY 2021

I was in that category until Dad’s diagnosis, and I can assure you, mesothelioma is not a word you want to have to learn. Reflections’ support network currently comprises men and women ranging in age from early 50s to their 70s. Every new sufferer that joins is a reminder that we need to be doing what we can to reduce the ongoing impact of this devastating disease on our community. Greg was 50 when a dry cough and sore chest took him to the doctor for a check-up. Having not worked for any prolonged periods with asbestos, the diagnosis to follow was the last thing he and his wife expected. In an interview a few months before his death, Greg said it was all about awareness. “It is also about educating people that you don't necessarily have to have been a smoker to get lung cancer," he said. Lyn said it was a shock to receive the devastating diagnosis of malignant mesothelioma when she had never worked in the building industry. “It is heartbreaking to have to share this awful news with my beautiful family and friends, particularly when it is a preventable disease,” she said.

An asbestos awareness module into the Certificate II in Building and Construction Trade Pathways has been introduced this year. As exciting as this is, it still puzzles me as to why, so many years after asbestos was banned in Australia, it has taken this long. Sending apprentices and trainees onto worksites without an understanding of asbestos puts them at risk of suffering its devastating effects later in life. With the DIY culture in Australia, we also need greater awareness in the general community. As we spend time more time at home due to COVID restrictions, will we look back in 30 years’ time and see the start of another wave? A national asbestos awareness campaign is something that should have been rolled after asbestos was banned in 2003. We are fortunate to have some of the world’s leading experts in asbestos-related disease here in WA. While they work on finding a long-term treatment for mesothelioma, we need to be doing what we can to ensure people are not exposed to its source. Asbestos knows no boundaries. While it might be too late for some, there is opportunity to increase awareness and, potentially, save lives. Knowledge is key. ED: www.reflections.org.au

Over the past 10 years, my knowledge of asbestos and its ongoing impact has grown exponentially. It’s what drives me MEDICAL FORUM | WOMEN ’S HEALTH

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GUEST COLUMN


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GUEST COLUMN

Women’s business can’t remain secret Kath Mazzella OAM has devoted years trying to remove the stigma around women’s gynaecological problems. I am a survivor of a radical vulvectomy. I guess I don’t need to explain what that means to a medical professional, yet it seems women are in the dark about what this is and what it can do. I hear that vulva cancer is hard to detect. Many women are often diagnosed and treated for thrush for long periods of time. Vulva cancer survivors say they are often misdiagnosed. I have seen women leave this earth before me because of this. I have grave concerns that medical professionals are not given enough education to know how to detect this cancer. Symptoms can either be a vulva irritation or a lump. Understandably, often it seems medical professionals are not well equipped or advised to check women’s vulvas for fear of sexual abuse. Which is why it is

imperative for women, themselves, to become more confident with their bodies, and with the risks and symptoms of any gynaecological conditions so if they are concerned about a vulval issue, they feel confident enough to request their doctor to check. The mental effect on women is enormous, not to mention the ripple effect on their partners and families. There is still so much stigma around these issues. A woman informed me that a female doctor told her, as she was being assessed before she went into surgery, that due to the lichen sclerosus which caused her cancer, her “vagina” was being removed during the operation. Yet, when wheeled into surgery, the male professor said he was removing her vulva not her vagina.

This woman said it felt like doctors were dumbing it down using vagina rather than vulva for the ‘average woman’ to understand. But that is like referring to a penis as testicles – imagine if men were told their testicles were to be removed due to cancer and came out of surgery with the penis removed instead. No wonder there is mass confusion. In my search for understanding to find out why all this stigma and misunderstanding existed, I came across the Latin word pudendum, meaning female genitalia and considered the shameful part of a woman. Hence the start of stigma, taboos and misquoting of the vulva. My message to doctors is to dare to be “vulva aware” for the sake of your mother, sister, daughter, work colleague, friend, or partner. www.kathmazzella.com

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Visit modalis.com.au to find out more about our services, locations, referral pathways and screening process.

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tms@modalis.com.au

MAY 2021 | 43


GynaePathWA is a dedicated Gynaecological subspeciality department, led by Dr Adeline Tan. We provide a complete Gynaecological and Reproductive Pathology Service

L-R: Drs Yancey Wilson, Colin Stewart, Bridget Cooke, Anastasia Backhouse, Adeline Tan

• • • • • • • • Contacts: Dr Adeline Tan: 9371 4524 Jean Paradise : 0438 275 980 44 | MAY 2021

Team of specialist gynaecological pathologists Team review of complex cases Team attends Gynae tumour conference at KEMH Advanced investigative procedures performed in-house Immunoperoxidase stains (inc hormone receptor studies) Flow cytometry Frozen sections Cytogenetics

GynaePathWA Specialist Gynaecological Pathology

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OPINION BACK TO CONTENTS

Dr Joe Kosterich | Clinical Editor

Going beyond labels Medicine can be a glass half empty profession. We tend to see problems and, understandably, worry about worst-case scenarios. On top of that there is frequent criticism of doctors from those in ivory towers for not “doing enough” or not following guidelines strictly enough or some other failure.

The change in vaccine rollout due to blood clot risk did have some women ask the reasonable question as to why the risk of blood clots was tolerated with the contraceptive pill.

Against this background it is worth noting that in women’s health we are doing quite well. And before you all scream, this is not mutually exclusive with the desire for or ability to do better. ABS data shows that the life expectancy for a woman born in 2017 was 85 compared to 74.2 years for a woman born in 1967. Not all of this is due to medical practice, but we do our bit. Cervical cancer incidence is decreasing, and breast cancer survival is increasing. In this issue we have articles on long-acting reversible contraception, new ways of assessing ovarian lesions and also premature ovarian failure. Egg freezing is an area attracting increasing interest and the issues are looked at in detail. Other topics include the team approach to breast cancer, use of testosterone in women and also how to support women who are breastfeeding. But women’s health is more than issues around reproduction. Heart disease remains the leading cause of death in women in Australia. Some may have “typical” presentations but others do not, as is described in the update on this topic. To round things out we have a piece on navigating diet fads. No group of people should be “pigeonholed”. Gemma Tognini, writing in the Weekend Australian put it well – “Women aren’t a monolith. We are not a cohort with one policy concern. We are not the gendered equivalent of the Shooters Fishers and Farmers Party.” I would add that not all women have identical health concerns or priorities either. The change in vaccine rollout due to blood clot risk did have some women ask the reasonable question as to why the risk of blood clots was tolerated with the contraceptive pill. It is a valid point as this is also a known side effect but does not stop it being taken – when the benefits outweigh the risks. Ultimately, we need to see people as individuals regardless of traits they may share with others. And treat each person as an individual doing our best for them based on their circumstances.

MEDICAL FORUM | WOMEN ’S HEALTH

MAY 2021 | 45


To freeze or not to freeze? By Dr Rose McDonnell, Obstetrician and Gynaecologist, Claremont Social egg freezing, affectionately known as “Eggsurance” by some, is a process whereby a woman has her ovaries stimulated by medication and then goes through an in-vitro fertilisation (IVF) cycle to collect eggs. These eggs are then cryopreserved using a technique called vitrification that avoids ice formation within the egg. They are then cooled to below the freezing point of water. They are thawed at a later stage when an embryo is to be made, either with a partner’s sperm or donor sperm. This embryo is then placed back in to the uterine cavity with the hope of a subsequent pregnancy. Oocyte (egg) cryopreservation is also used to preserve fertility in women undergoing treatment for a medical condition that may damage fertility or reduce the chance of natural conception. Increasingly women are considering egg freezing whilst traversing the obstacle course of adulthood, establishing their careers and forming a romantic partnership. The COVID pandemic has highlighted several barriers to meeting a partner and having a family. In fact, rates of IVF have increased due to less travel, changes to work practices and perhaps a renewed perspective on mortality and family. When considering the costs of egg freezing, one should consider not only the financial but the social costs and the impact of pregnancy later in life on the individual woman and the child born. The majority of egg freezing cycles are not covered by Medicare. The number of cycles required to obtain the suggested 20-30 eggs varies due to egg reserve and the age-related impact on egg quality. For those women using their cryopreserved eggs in the future, the eggs generally behave the way you would expect for the age at which they were frozen. When counselling women on outcomes of pregnancy as a result of egg 46 | MAY 2021

Key messages

Egg freezing is increasingly considered by women

There is a complex interplay of many factors. Informed choice is key

Ultimately the decision rests with the woman and what she feels is best for her reproductive future. cryopreservation, the age at which the pregnancy occurs should be factored in.

The likely candidates? Women between 30-37 are encouraged to consider egg freezing and should take into account factors such as family size expectations, age, career aspirations, finances, relationship status and whether opportunity exists to meet someone that shares similar family desires and whether there is a family history of premature menopause. The patient’s perspective (a half glass full or empty approach to life) factors in to how a woman may view fertility and egg freezing.

Some women may prefer a watch-and-wait approach having considered their options. Some are comfortable with having a sperm donor if they don’t meet someone they wish to have a family with and, as a result, may be more proactive in oocyte cryopreservation. Social media and ‘celebrity baby stories’ have impacted how women and, indeed couples, view fertility. What is often not discussed is the older woman’s journey to have a baby (e.g. several rounds of IVF miscarriages, use of eggs cryopreserved at a younger age or egg or embryo donor). In an age where women aspire to higher levels of education and are driven to have successful careers and being financially independent, there are questions as to whether egg cryopreservation devalues women in the workforce. Some argue it detracts from support for women who have had children rejoining the workforce. Some global companies (e.g. Google, Apple and Facebook) offer egg freezing to their employees as a perk. Is this a forward-thinking MEDICAL FORUM | WOMEN ’S HEALTH

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move to give women a choice or a way to delay childbearing to enhance productivity; and how does this affect career trajectory if opting in or out? Companies in the United States have been set up to host egg freezing parties to educate young women on the benefits of egg freezing to ensure that they have the option of having a child when they feel ready (usually later in their 30s or 40s) when their careers are established. This begs the question as to whether it preys and capitalises on a woman’s anxiety regarding having a child as she ages. Currently eggs can be preserved for 10 years in Western Australia and the latest data shows that only 10% of women who freeze their eggs use them in the future. Some decide to have a sperm donor or meet someone and fall pregnant, hence their eggs are not used. Others choose not to have a child but still appreciate having had the option. If eggs are not used the options thereafter can be to allow them

to thaw and succumb, donate to research or donate to another woman. In the future we may be counselling women on preserving a portion of their ovary with the hope of preserving thousands of eggs, which could be available for fertilisation if and when a woman decides to have a child. This may negate the need to undergo hormonal stimulation to obtain eggs for future use and reimplantation of ovarian tissue may reduce the impact of menopause for women of the future. My patient or I want to freeze my eggs. What next? So, your patient, or perhaps you, have read everything there is to read on Google, blogs and social media. The next step is to review preconception health with your GP and refer to a doctor in the area of Fertility Medicine. At this consultation general health is reviewed and the reasons for seeking fertility preservation explored. A test of egg reserve and baseline fertility bloods are usually

conducted to give each patient an overview of their reproductive options. Then a decision can be made to go ahead with oocyte freezing or review the patient’s circumstances at a later time. The psychological impact of discussing the likelihood of having a child in the future cannot be underestimated and a supportive team of doctors, nurses, fertility counsellors and, if necessary, a psychologist, is available if extra support is required. Patients are encouraged to speak to those close to them for emotional support. Egg freezing can create a false expectation that it will guarantee having a baby in the future. As a society it also raises questions as to the value that we place on women and the subliminal expectation that women should and are expected to have a child to fulfil their “womanly obligations”. Like all choices, the option should be available to women regardless of their income and childlessness should be, and is, an acceptable lifestyle choice. Author competing interests – nil

Why is BreastScreen WA asking women about their Covid vaccination? As you are no doubt aware the Commonwealth Government has committed to a nationwide COVID-19 vaccination program to be completed by the end of 2021. There is no evidence that the COVID-19 disease or COVID-19 vaccination has any adverse effect on the breast tissue. Some recently published medical studies have reported a small incidence of mild lymph gland swelling in the axilla on the side of the inoculation for up to 6 weeks after the vaccination. BreastScreen WA is not recommending that women delay or reschedule their screening appointments. BreastScreen WA is asking your patient questions about the date, arm and brand of COVID-19 inoculation, so the consultant radiologist has this information when they interpret your patient’s mammogram images. If you have any queries about this matter, please contact BreastScreen WA’s Liaison GP at eric.khong@health.wa.gov.au

Women may book online www.breastscreen.health.wa.gov.au or phone 13 20 50 MEDICAL FORUM | WOMEN ’S HEALTH

Mar ‘18

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MAY 2021 | 47


Perth Breast Cancer Institute (PBCI) Breast Clinic A newly established Breast Clinic providing rapid assessment for patients with Breast Problems, located in the new Hollywood Hospital Consulting Centre.

Providing assessment and investigation for your patients with a breast symptom, such as a benign or suspicious breast lump, breast pain, nipple discharge. Rapid investigation for your patients with an imaging (mammogram or ultrasound) detected abnormality. This assessment is performed in conjuction with Perth Radiological Clinic, now located at the Hollywood Consulting Centre. Patients can be seen by one of three very experienced Breast Physicians, and where approriate, undergo breast imaging and diagnostic biopsy on the same day.

Assessment of women with dense breasts.

Advice regarding family history of breast cancer of other risk factors.

Patients requiring further management can be on-referred (after discussion with their General Practitioner) to the Multidiciplinary team of Breast and Oncoplastic Surgeons, Medical Oncologists, Genetic Counsellor, Breast Nurses, Clinical Psychologists and other dedicated support personnel at BCRC-WA.

The Perth Breast Cancer Institute - Breast Clinic is located at Suite 404 on Level 4 of the Hollywood Consulting Centre. A referral template can be found on our website. https://bcrc-wa.com.au/perth-breastcancer-institute-pbci/ breast-clinic/

Where appropriate, patients will also have access to a Comprehensive Clinical Trial Program.

Referrals to: Suite 404, Level 4 Hollywood Consulting Centre, 91 Monash Avenue Nedlands 6009 P (08) 6500 5576 | F (08) 6500 5574 E reception@bcrc-wa.com.au Healthlink EDI breastci

48 | MAY 2021

www.bcrc-wa.com.au

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Where have my periods gone? By Dr Tamara Hunter, Reproductive Endocrinology and Infertility Specialist, West Perth The prevalence of premature ovarian insufficiency (POI) is approximately 1%. It is a clinical syndrome defined by loss of ovarian activity before age 40 and characterised by menstrual disturbance (oligoamenorrhea), raised gonadotrophins and low oestradiol.

Key messages

Premature ovarian insufficiency affects 1% of women

There are multiple causes, but no cause may be identified

Menopause hormone therapy is the mainstay of treatment.

Women with POI may present with the typical symptoms of oestrogen deficiency, such as vasomotor symptoms, however the clinical presentation may vary. Some may not experience any symptoms, and this is less likely in those with primary amenorrhea. To illustrate, here are two cases. A 28-year-old couple present with primary couple infertility. She has irregular cycles 21-60 days. Pelvic ultrasound shows an antral follicle count of 3, AMH is 0.6 pmol/L and a Day 2 FSH of 24IU/L. Within three months was amenorrheic and developed hot flushes. A 17-year-old girl presents for investigation of primary amenorrhea. She is a twin and her sister had menarche aged 14. She has secondary sexual characteristics and short stature. Blood tests revealed FHS 55 IU/L, LH 16 IU/L and oestradiol <25 pmol/L. Transabdominal ultrasound revealed 1mL size ovaries along with

a juvenile uterine size. Karyotype revealed 45XO – Turners syndrome. Both women have POI. The causes of POI are wide ranging: 10-12% of women with POI have chromosomal abnormalities (majority being X chromosome abnormalities). It is important to check for presence of Y chromosome due to the risk of gonadal neoplasia. Fragile X syndrome is an X-linked condition caused by a mutation of the FMR1 gene leading to mental retardation predominantly in men. Women carrying the mutation have a 13-26% increased risk of developing POI. Testing for Fragile X premutation in women with POI is important as this diagnosis has implications for her and her family. Premutation carriers have an increased risk of developing cerebellar gait ataxia and intention

Effects of POI

MHT indicated?

Comments

Vasomotor symptoms

Yes

MHT is indicated to treat vasomotor symptoms in POI until age of natural menopause

Genitourinary symptoms

Yes

Either systemic or local estrogen is effective

Bone health

Yes

MHT is recommended to maintain bone health and prevent osteoporosis

Cardiovascular health

Yes

MHT initiated early is thought to reduce risk of CVD; continue to age of natural menopause

Sexual function

Yes

MHT is a starting point to normalise sexual function; local estrogen helps dyspareunia

Neurological function

?

MHT reduces the possible risk of cognitive impairment and should be in place until the age of natural menopause

Life expectancy

?

Appears reduced due to CVD; MHT may have indirect benefit

Quality of life

?

Appears reduced; MHT may be of indirect benefit

Adapted from POI Guideline Development Group (2015), Management of premature ovarian insufficiency. Guideline of the European Society of Human Reproduction and Embryology.

MEDICAL FORUM | WOMEN ’S HEALTH

tremor. Routine screening for autosomal genetic mutations is not recommended unless there is evidence suggesting specific mutation (e.g. Blepharophimosisptosis-epicanthus-inversussyndrome – BPES). Autoimmune disorders are more frequent in those with POI than the general population, and POI is more frequent in populations with autoimmune disorders. Identification of those with subclinical or latent Addison’s disease with adrenocortical antibodies and those with autoimmune hypothyroidism by screening for thyroid antibodies is important. Mumps oophoritis has been considered a cause of POI in 3-7% of cases. Infection screening in women with POI is not indicated. Medical interventions (e.g. chemotherapy radiotherapy or surgical procedures such as bilateral ovarian cystectomy for endometriomas) can lead to POI. This risk with these interventions should be discussed as part of the consenting process. In a significant number of cases the cause is not identified. There are no ideal diagnostic biomarkers to confirm diagnosis. It is confirmed by a period of four to six months where there is amenorrhea or oligomenorrhea and two serial measures of FSH above 25 IU/L on two occasions over four weeks apart. AMH is not sufficiently discriminative for a diagnosis of POI. There is no indication to include ultrasound. As ovarian function may fluctuate with POI, follicular activity may be seen, and this doesn’t differentiate POI from other diagnoses. Menopause Hormone Therapy (MHT) is the mainstay of treatment in POI. In addition to the management of symptoms associated with hypoestrogenism (e.g. hot flushes) there are multiple reasons to consider introducing MHT (see Table 1). continued on Page 51

MAY 2021 | 49


OMG! O-RADS and IOTA ADNEX are here By Dr Emmeline Lee, Radiologist, West Leederville Ovarian cysts are incredibly common. It is important for imaging professionals to issue accurate reports so that benign lesions are not worked up unnecessarily, whilst not dismissing potentially significant ones.

using clinical and ultrasound features to determine a lesion’s risk of malignancy. Its accuracy has been validated in multiple trials and has won the hearts of many users (including mine!) for its ease of use and practicality.

Many ovarian lesions are physiological (especially in premenopausal women) and will resolve on their own. Some are benign but may need follow-up due to potential for complications such as dermoid cysts (teratomas) and endometriomas. Some lesions are worrying enough to be referred straight to a gynaecological oncologist.

It has also been popular with clinicians as it helps guide whether the lesion requires referral to a specialist and, if so, to whom (i.e. a general gynaecologist or gynaecological oncologist).

has been largely based on expert opinion.

Ovarian malignancies are uncommon but are the leading cause of death amongst gynaecological malignancies. There is a much better survival rate if operated on by sub-specialist gynaecological oncologists. However, many lesions can be managed either by a general gynaecologist, or by repeat imaging alone.

The International Tumour Analysis group (IOTA) has led the way over the past 20 years in trying to standardise nomenclature for adnexal lesions. Other groups, such as the Society of Radiologists in Ultrasound (SRU) have attempted to produce guidelines to help radiologists in their recommendations for management of adnexal lesions.

Radiologists rely on pattern recognition to decide if a lesion is worrying or not. Until recently, much of the data to determine accuracy

The IOTA group have produced a risk stratification tool called the Assessment of Different NEoplasias in the AdNEXa (ADNEX) model

Simple cysts (on TV ultrasound) up to 5cm in size are O-RADS 2 lesions that don’t need further follow-up.

Multiple national societies have recommended the use of the IOTA ADNEX model, including the American College of Obstetricians and Gynaecologists, and the Royal College of Obstetricians and Gynaecologists. The IOTA ADNEX model has been shown prospectively to have an accuracy rate of 92-95% with a false positive rate of 10%. It is much more accurate that the Risk of Malignancy Index (RMI). CA-125 can be incorporated into the calculation if available, but this will only differentiate between Stage 1 Ovarian cancer from Stage 2-4 Ovarian cancer. In 2018, the American College of Radiology published a risk

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50 | MAY 2021

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CLINICAL UPDATE


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Key messages

Ovarian lesions are common and assessment challenging

The O-RADS system has advanced risk stratification

Better assessment leads to better outcomes.

stratification classification system called O-RADS, which also has guidelines for management. O-RADS can be used for ultrasound and MRI, but is most useful for ultrasound, as the usual first line modality for investigating pelvic lesions. MRI is usually used for problem solving. O-RADS can be used for all adnexal lesions and has been vigorously studied in low- and high-risk populations. There are 5 categories of risk in the O-RADS classification: O-RADS 1 – Normal ovary O-RADS 2 – Almost certainly benign (<1% risk of malignancy O-RADS 3 – Low risk of malignancy (1 to <10% risk of malignancy) O-RADS 4 – Intermediate risk of malignancy (10 to <50% risk of malignancy) O-RADS 5 – High risk of malignancy (>50% risk of malignancy). Faced with an adnexal lesion, a radiologist will use pattern recognition to classify a lesion. Most lesions will be easily categorised as normal (i.e. simple follicle or corpus luteum – O-RADS 1 lesions), or

MEDICAL FORUM | WOMEN ’S HEALTH

simple cysts/ haemorrhagic cysts/ endometriomas (O-RADS 2 lesions) or dermoids (O-RADS 3 lesions). Most lesions seen on imaging are benign, and are in the O-RADS 1, 2 or 3 categories. Some lesions are harder to categorise. If unsure what the lesion is, the IOTA-ADNEX can help identify the risk category. This then gives a lesion a numerical risk of malignancy (e.g. 25%), and then it can be classified into one of the O-RADS categories of risk (e.g. O-RADS 3). Management will then be dictated on this basis, or by using the O-RADS Chart which is available on

the ACR website as a free resource (https://www.acr.org/ClinicalResources/Reporting-and-DataSystems/O-Rads). Radiologists are increasingly using the IOTA ADNEX model for risk calculation of adnexal lesions and the O-RADS reporting system as a simple, user-friendly and practical tool to ensure accurate reporting and appropriate follow-up for women with adnexal lesions. – References available on request Author competing interests – nil

Where have my periods gone? continued from Page 49 Many women worry about the long-term effects of MHT. Women with POI should be informed that there is no increased risk of breast cancer if MHT is introduced before the age of natural menopause. Progestogen should always be given in combination with oestrogen therapy to protect the endometrium in women with an intact uterus or where progestogens are indicated such as endometriosis. 17B-estradiol is preferred to ethinyl oestradiol or conjugated equine oestrogen for oestrogen replacement. The strongest

evidence for endometrial protection is with oral progestogen given cyclically. Patient preference for route of administration of MHT (transdermal vs oral) must be considered, as is the need for contraception. Untreated POI is associated with reduced life expectancy, largely due to cardiovascular disease. Women with POI should be advised to reduce cardiovascular risk factors by not smoking, regularly exercising and maintaining a healthy weight. Bone health should also be monitored throughout life. – References available on request Author competing interests – nil

MAY 2021 | 51


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Heart Disease in Women – Different Symptoms, Different Syndromes By Dr Michelle Ammerer, Interventional Cardiologist, Subiaco Heart disease remains the leading cause of death in women in Australia and the Western world. Women are twice as likely to die from heart disease compared to any other disease.

Although this syndrome is rare it is overwhelmingly seen more commonly in younger women who present with an acute coronary syndrome. Diagnosis requires angiography.

When women develop heart disease their mortality is higher than that of men. Interestingly, over the last three decades, heart disease mortality has declined for both women and men especially in the over 65 age group. This improved mortality, however, has not been observed in younger women under the age of 65 with heart disease.

Risk factors for SCAD include not only female sex, but fibromuscular dysplasia and the peri-partum period. The classical presentation is a young healthy woman without traditional coronary risk factors presenting with sudden severe chest pain.

Coronary Artery Disease remains the most common form of heart disease. It is a consequence of coronary atherosclerosis and predisposes to cardiac ischaemia and myocardial infarction. For women and men, the traditional risk factors include diabetes, smoking, obesity and overweight, physical inactivity, hypertension, dyslipidaemia, family history/genetic factors and depression. Over recent decades gender specific risk factors for CAD in women have also been identified. These include pregnancy induced hypertension, pre-term delivery, gestational diabetes, autoimmune disease and breast cancer treatment. Some traditional risk factors pose different risks for ischaemic heart disease in women compared to men. For example, diabetic women have a greater risk of developing heart failure compared to men. Diabetic women are more likely to develop heart failure and other vascular disease such as stroke. There is also a higher prevalence of hypertension in women over the age of 65 than in men. Whilst women will often display the typical symptoms of angina in acute coronary syndromes such as retrosternal chest tightness and heaviness, women may not uncommonly present with atypical symptoms. Such less-specific symptoms include dyspnoea alone, sweating, nausea, light headedness and abdominal, neck, back and jaw pain. MEDICAL FORUM | WOMEN ’S HEALTH

Key messages

Heart disease is the leading cause of death in women

Women have the usual, but also other risk factors

Be alert for different symptoms and syndromes.

The treatment of acute coronary syndrome does not differ for women and men. Immediate management with aspirin, hospitalisation and early intervention with coronary angiography is important for accurate diagnosis and timely intervention.

Other syndromes Coronary microvascular dysfunction (microvascular angina) is defined as limited coronary flow reserve and coronary endothelial dysfunction. It is identified when a patient with typical angina has no significant obstructive coronary disease at angiography. Management of microvascular angina in women includes risk factor modification and lifestyle changes. Medical therapy for microvascular dysfunction includes the usual antiischaemic drugs such as nitrates, beta blockers, ACE inhibitors and statin therapy. Spontaneous Coronary Artery Dissection (SCAD) is defined as a sudden separation between the layers of the coronary artery wall. An intimal flap is created, and intramural haematoma temporarily obstructs myocardial blood flow.

The condition is important to diagnose accurately as the treatment and management are often conservative and the use of anti-platelet therapy. Intervention with coronary stents is best avoided. Stress induced cardiomyopathy (Broken heart syndrome/Takotsubo Cardiomyopathy) has been identified since 1990. It was first described in Japan and named after an octopus trapping pot that has a round base and narrow neck which resembles the left ventriculogram during systole in these patients. It presents most commonly in postmenopausal women and is often precipitated by extreme physical or emotional triggers. The clinical presentation, electrocardiographic findings and troponin profiles are often similar to those of an acute coronary syndrome. This syndrome is identified by coronary angiography excluding the presence of significant obstructive disease and typical echocardiographic features. Whilst the underlying cause of this syndrome remains uncertain, treatment is based on medical therapy traditionally used for heart failure such as beta blockers and ACE inhibitors. Recovery is usually seen within six weeks with left ventricular function often returning to normal on echocardiogram. In summary women are different to men – and their hearts and their symptoms differ too. We should all stay aware of that. Author competing interests – nil

MAY 2021 | 53


Testosterone therapy in postmenopausal women By Dr Ashley Makepeace, Endocrinologist, Palmyra The use of testosterone therapy in females has been addressed in the first global consensus position statement. It aimed to provide guidance on assessment and management of female sexual dysfunction and indications for testosterone therapy.

Key messages

Treatment of HSDD is the only evidence-based indication for testosterone therapy in postmenopausal women

In 2020 the TGA approved a

It highlighted the only evidencebased indication for testosterone therapy was treatment of hypoactive sexual dysfunction disorder (HSDD) in postmenopausal women. There are insufficient data to support the use in premenopausal women and there is no data to show benefit to cardiometabolic, musculoskeletal or cognitive health or wellbeing. Women at high risk for cardiometabolic disease and those with a history of breast cancer were excluded from the randomised controlled trials.

transdermal testosterone cream for postmenopausal women with HSDD

A trial of testosterone therapy may be appropriate for some women whose symptoms are not addressed by MHT. An Australian perspective on the global consensus statement, published in the MJA in 2020, proposed an algorithm for considering testosterone treatment in postmenopausal women, recommending menopausal

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hormonal therapy (MHT) be considered before initiating testosterone. The issue of low sexual desire may not be readily volunteered and may be long-standing. A community based sample of Australian women aged 40-65 reported more than two thirds had low sexual desire and almost one third met criteria for HSDD. There are several classifications for HSDD. Generally, it is defined as at least six months of lack of spontaneous or responsive sexual desire or behaviour change to avoid sexual activity which causes personal distress. Clinical assessment of women with sexual problems includes medical, sexual and social history to help identify potential contributing

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CLINICAL UPDATE factors. In post-menopausal women, menopausal hormonal therapy (MHT) can improve vasomotor symptoms (VMS), urogenital symptoms and mood disturbance and vaginal oestrogen formulations benefit vulvovaginal atrophy. It would seem reasonable to see if MHT addresses potential contributing factors to sexual dysfunction prior to a trial of testosterone therapy. Of note, oral oestrogen raises sex hormone binding globulin (SHBG) reducing available free testosterone, this effect is not seen with topical preparations. Testosterone is generally measured by immunoassay which lack precision at the lower concentrations found in women. Androgen levels decline steadily during reproductive years with a nadir in their early 60s. Measurement of testosterone is not used to diagnose HSDD, as it does not correlate with testosterone levels. Testosterone and SHBG are measured to exclude high levels prior to starting testosterone

MEDICAL FORUM | WOMEN ’S HEALTH

therapy and to monitor biochemical response to treatment. In addition to baseline biochemistry, it is useful to gauge symptoms prior to starting and after commencement of treatment. Similar to what is available through the Australasian Menopause Society, information sheets for assessment of symptoms prior to and after initiation of MHT. Reassessment of serum testosterone levels three to six weeks after initiation of testosterone therapy or dose adjustment is recommended, aiming for pre-menopausal physiological testosterone levels. If there is no symptomatic benefit after six months, treatment is discontinued. Adverse effects of testosterone therapy, when achieving the physiological levels of premenopausal women, are limited to excess hair and acne and not associated with serious side effects. Ongoing monitoring of testosterone levels and for signs of androgen excess continues every six months. Safety data is limited to 24 months of treatment.

formulations have been the same as those designed for treatment of men, with potential risk of excessive dosing. In November 2020, the Therapeutic Goods Administration (TGA) approved a 1% transdermal testosterone cream for postmenopausal women with HSDD. Small clinical studies have shown 5-10mg daily achieved total and free testosterone levels in the pre-menopausal range. Recommended further reading includes the MJA article with a proposed algorithm for assessment and treatment of HSDD and information sheets such as but not limited to what is available through the Australasian Menopause Society. – References available on request Author competing interests – nil

Read this story on mforum.com.au

Until recently, available testosterone

MAY 2021 | 55


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Multidisciplinary care for breast cancer patients By Professor Arlene Chan, Medical Oncologist, Nedlands It has been well recognised that multidisciplinary care for patients with cancer results in many benefits for patients. Cancer Australia states that adopting multidisciplinary care results in increased survival, higher likelihood that treatment aligns with evidence-based guidelines, shorter timeframes between diagnosis and treatment commencement, greater patient access to accurate information and greater patient satisfaction. With breast cancer (BC), it is generally accepted that the attendees of multidisciplinary team meetings include breast surgeon, medical oncologist, radiation oncologist, pathologist, radiologist, breast physician and breast nurse. For women and men diagnosed with breast cancer, it is daunting to understand the plethora of information about their diagnosis and treatment options, as well as cope with the need for appointments with other specialists in the team and additional investigations. The need for a coordinated approach to managing BC patients is undoubtedly a challenge and has been cited as an area requiring further attention and research. Studies reveal that over 90% of health professionals agree that clinical decision-making and provision of evidence-based medicine are best achieved when patients are discussed at multidisciplinary meetings. However, it has also been demonstrated that poor communication between team members and the lack of prospective data collection as to the treatment received and patient outcomes prevent ongoing quality assurance. A team should comprise breast surgeons (ideally with oncoplastic expertise), medical oncologists, breast physicians, a genetic counsellor, nurses (for early and metastatic BC patients) and clinical psychologists and have a focus on education of both other health care providers and the community. MEDICAL FORUM | WOMEN ’S HEALTH

Key messages

Multidisciplinary care has many benefits

Team meetings and coordination is critical

Each patient is on their own journey.

Availability for GP or patient-self referral in the setting of abnormal breast symptoms, heightened family risk of BC, abnormal screening mammography or confirmed malignant breast lump are important. Team members need to regularly attend multidisciplinary meetings to enable a coordinated approach for patients and particularly for those with complex medical and social factors, diagnostic issues, which may require interventional image-guided biopsies, and the interpretation of pathological findings. The Breast Cancer Research Centre – WA (BCRC-WA) has established a clinical arm, the Perth Breast Cancer Institute, to provide delivery of comprehensive care, including provision for patients to be offered

involvement in clinical trials at a single site. This has been considered a strength for a multidisciplinary care approach to BC patients. Patients who are appropriate for clinical trials have an opportunity to access neoadjuvant, adjuvant and metastatic BC trials. Patients recommended for and consenting to clinical trials are supported in this aspect of their care by one or more staff within the BCRC-WA. To achieve optimal BC outcome, the application of evidence-based treatment needs to be pursued by the team. Yet optimal patient care also requires guidance, education and ongoing support of individual patients and their families. Each person is on an individual patient journey and assigned a BC nurse who can help coordinate care. Published evidence underlies the importance of a multidisciplinary approach providing all the above elements of patient care, which will ideally result in the best possible patient outcome. – References available on request Author competing interests – nil

MAY 2021 | 57


Navigating the maze of fad diets By Jo Beer, Advanced Accredited Practising Dietitian It can be confusing and frustrating determining the optimum dietary intake for our patients and ourselves. However, it is increasingly clear that the best approach is a Mediterranean diet (MedDiet). Although the precise content of such a diet varies in different studies, the principles rely on eating a broad selection of plant-rich, whole foods, complemented by fresh fish, lean meat and extra virgin olive oil. This approach has been well recognised for many years and is solidly validated, but the plethora of articles, books, websites, celebrity experts, bloggers, personal trainers (practically anyone who eats) extolling the virtues of the latest, greatest diet is a constant distraction. Good health is, of course, not just about what you eat. Obtaining

factor for chronic disease and is not fully offset by achieving the recommended amounts of daily exercise. Exercise also improves sleep, can reduce stress, and encourages neurogenesis and synapse formation in the brain, potentially leading to improved cognitive functioning.

Key messages

Keep it simple Promote a Mediterranean style diet Get an accredited practising dietitian to assist with your patients’ individual requirements.

Regimented programs of specific macro- and micronutrient intake and fasting attract interest (e.g. intermittent fasting, the 5:2 diet, fast 800, ketogenic, and paleo diets). They can lead to short-term weight loss but are not generally sound long-term strategies for good health.

adequate sleep, exercise and coping with stress are all crucial aspects of maintaining optimum health. A recent comprehensive sleep survey of Australians showed that up to 45% of people don’t get enough sleep, increasing the risk of chronic diseases (e.g. CVD, diabetes, mental health problems) and weight gain. Prolonged sitting (over eight hours daily) is established as a significant risk

Long term, sustainable healthy eating programs need to be easily assimilated into daily living especially for families eating together. It is not practical when

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CLINICAL UPDATE significant effect on overall health or weight loss if the rest of the diet is poor.

different family members pursue radically different eating patterns. Simplicity is key to the sustainability of any long-term eating strategy. Adhering to a MedDiet, which includes plant-rich whole foods, naturally leads to a low intake of highly processed foods, refined carbohydrates and sugars, whilst ensuring an adequate intake of fibre. Whilst various ‘superfoods’ are frequently highlighted as shortcuts to health and vitality, the real key is selecting a broad range of healthy foods.

LAWLEY LAWLEY LAWLEY LAWLEY

The MedDiet is probably the most widely evaluated dietary regime in the scientific literature. Typically, it is characterised by a high intake of vegetables (e.g. tomatoes, eggplant, onion, garlic, green vegetables), legumes (chickpeas, lentils, beans), fruit, nuts, and wholegrains eaten in conjunction with seafoods, lean meat and extra virgin olive oil.

of endothelial function, and antithrombotic effects. These changes are likely attributable to bioactive ingredients such as polyphenols, monounsaturated and polyunsaturated fatty acids, and fibre.

One of the most exciting emerging areas of research is the link between diet, the gut microbiome, the brain, and health. Even a few years ago, suggestions that bacteria and other gut microorganisms could influence brain function and health would have been ridiculed. Positive effects on the human microbiome have been demonstrated in those following a MedDiet. This is due, at least in part, to ingested plant foods rich in fibre that are fermented by gut bugs, producing a range of bioactive compounds beneficial to health.

In practice, recommending five different plant-based foods each day, which are varied over the Nutritional science evolves, but it week, is a simple starting point. has become increasingly clear that Although this sounds daunting to a predominately plant-based food many patients, a dietitian can assist plan, supplemented with oily fish in recommending different salad and lean meat, such as the MedDiet, ingredients, vegetables, grains, is the best starting point. Optimum health also requires consideration nuts, and seeds tailored to the of broader lifestyle factors, patient’s preferences and income, Suggested mechanisms underlying including sleep and activity. so that this can be easily achieved. the beneficial effects of the ® ® ® ® ‘Superfoods’ (some of which MedDiet include reduction of blood Does Does the the woman woman have have laboratory laboratory values values Does Does the the woman woman have have laboratory laboratory values values – References available on request are nutrient rich with high levels lipids, inflammatory and oxidative consistent consistent with with a consistent low a low testosterone testosterone level? level? consistent with with a low a low testosterone testosterone level? level? antioxidants or protective plant stress markers, improvement in Author competing interests – nil • Starting • Starting dose 0.5mL (5mg) (5mg) applied applied • dose Starting •0.5mL Starting dose dose 0.5mL 0.5mL (5mg) (5mg) applied applied compounds) are unlikely to have a insulin sensitivity, enhancement Two samples taken in the Two samples taken in the once once daily daily once once daily daily One sample taken in the

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www.lawleypharm.com.au 1800 627 506 (Australia) or +61 8 9388 0096 www.lawleypharm.com.au www.lawleypharm.com.au www.lawleypharm.com.au www.lawleypharm.com.au 1800 1800 627 627 506 506 1800 1800 627 627 506 506 2 /Harrogate 15A Harrogate West Leederville WA 6007, info@lawleypharm.com.au Unit Unit 2 / 15A 2 / 15A Harrogate Harrogate West West Leederville Leederville WAStreet 6007, WA 6007, info@lawleypharm.com.au. info@lawleypharm.com.au. Unit Unit 2 /Street 15A 2Unit /Street 15A Harrogate Street Street West West Leederville Leederville WA 6007, WA 6007, info@lawleypharm.com.au. info@lawleypharm.com.au.

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Update on contraceptive implants By Dr Alison Creagh, Medical Educator, SHQ, Perth Over the past few years, there have been changes to recommendations on contraceptive implants with practical implications for clinicians. The most important change in practice is in the recommended site for implant insertion. It is important to insert contraceptive implants in a consistent position to reduce the incidence of complications during insertion and removal, and to assist practitioners to locate a device when removal is required. Worldwide, there have been a number of reports of complications when nerves or blood vessels have been injured during insertion. Anatomical studies performed over the past few years have showed that the risk of complications is lowest if implants are inserted superficially and over the triceps muscle. The guidance is to insert 8-10cm above the medial epicondyle of the non-dominant arm at a distance of 3-5cm posterior to the groove between the biceps and the triceps muscle. An additional mark should be made 5cm above the insertion site to guide placement of the local anaesthetic and the implant along the same track. It’s very important to insert the implant as superficially as possible to reduce the risk of complications and difficulties with removal. A quick tip for the insertion procedure is to insert only the tip of the needle

Key messages

The recommended site of insertion for contraceptive implants has changed

Removal is more challenging than insertion

Implant change can be delayed in cases of lockdown. under the skin before lowering the insertion device to the horizontal position and raising (or ‘tenting’) the skin above the needle, before inserting any further. What should we do if an implant is due for replacement, and the current one is not in the correct position? It is safer for the patient if the new implant is placed over the triceps, according to the new recommendations, rather than replaced in the original position, which would increase the risk of nerve or vessel complications. Contraceptive implant removals are usually more challenging to perform than insertions. Some practical tips are: • Don’t start the procedure if the lower end is not easily palpable. Instead, refer to an experienced practitioner who can perform removal under ultrasound guidance, such as the experts at KEMH. • Ensure that the incision made is a vertical one. We are aware that some practitioners have

been taught the alternative, but removals are much easier if the manufacturer’s advice to do a vertical incision is followed. • Stabilising the two ends of the implant between finger and thumb throughout the removal generally makes the process easier. This can take some practice. If people would like to practice this on a simulation arm, they can get in touch with Clinical Education at SHQ. Refresher videos on insertion and removal of contraceptive implants are available online. Questions have been asked about extended use of long-acting contraception during COVID lockdowns. Based on reasonable evidence that contraceptive efficacy remains high for contraceptive implants, copper IUDs and the higher dose levonorgestrel IUD (Mirena) for a year beyond their recommended duration of use, an Australian consensus statement was published by the SPHERE collaboration last year. During times when face-to-face health care is limited to urgent issues only, patients who are due for replacement of their implant, copper IUD or higher dose levonorgestrel IUD can be advised that replacement can be postponed for up to a year after the usual recommended time. The family planning organisations across Australia have collaborated to provide brief evidence-based guidance on topical clinical issues, for example on managing bleeding with progestogen only contraception, or obesity and contraceptive implants. This is available by clicking the ‘For Clinicians’ tab on the SHQ website. – References available on request Author competing interests – nil

Implanon arm

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Implanon inserter

MAY 2021 | 61


Complex non-melanoma skin cancer patients? Refer cases to the Non-Melanoma Skin Cancer Advisory Service for multidisciplinary review

The benefits of a multidisciplinary approach to patient management are well known. The Non-Melanoma Skin Cancer Advisory Service (NMSCAS) has been established to enhance the care of patients with complex non-melanoma skin cancers. To submit cases to the NMSCAS for advice or management, visit genesiscare.com/au/refer-a-patient then click on Oncology to download the forms. Case information must be received no later than 1 week prior to the scheduled meeting.

 NMSCAS meets every third Thursday of the month  Clinipath Pathology 310 Selby Street North Osborne Park WA 6017

NMSCAS specialist team: Dermatology Dr Kate Borchard Dr Judy Cole Dr Glen Foxton Dr Louise O’Halloran Dr Jamie Von Nida Dr Yee Tai Pathology Dr Trevor Beer Dr Gordon Harloe Dr Joseph Kattampallil Dr Stephen Lee Dr Ben Ryan Plastic surgery Dr Adrian Brooks Dr Sharon Chu Dr Brigid Corrigan Dr Mark Hanikeri Dr Daniel Luo Dr Linda Monshizadeh Dr Remo Papini Radiation Oncology Dr Sean Brennan Dr Eugene Leong Dr Susan Mincham Dr Evan Ng Dr Kasri Rahim Dr Craig Wilson Dr Yvonne Zissiadis

All enquiries: mdtskinwa@genesiscare.com 62 | MAY 2021

0419 610 298

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CLINICAL UPDATE

Keeping an open mind diagnosing cervical disease By Dr Jenny Grew, Pathologist, Perth SARS-CoV-2 and COVID-19 has dominated the public health headlines for more than 12 months, and yet, there is a shadow story of viruses and vaccines, one in which global inequities are writ large. One woman dies of cervical cancer every two minutes and nine in 10 of those deaths occur in low-andmiddle income countries. Cervical cancer is a preventable disease and curable if detected early and adequately treated. We received in the laboratory both a cervical screening test and an endometrial curetting sample from a 37-year-old woman with the clinical history stating “Menorrhagia”.

Figure 1

Key messages

Thorough evaluation and correlation between all samples is important

It is essential to keep an open mind

Vaccination and screening are needed to achieve elimination threshold of cervical cancer.

The cervical screening test (CST) underwent routine HPV testing for HPV 16, 18 and HPV “other”. As none of these were detected, the result of the CST for this patient was reported as HPV negative. The concurrent endometrial sample was submitted for routine histological processing and the H&E-stained section was reviewed by the reporting pathologist. It showed proliferative endometrium with evidence of breakdown. However, in addition to endometrial tissue, a few small strips of atypical squamous epithelium and admixed inflamed endocervical mucosa were seen (Figure 1). Further assessment utilising p16 immunohistochemistry was performed and the atypical squamous epithelium showed strong diffuse p16 expression (Figure 2), in keeping with a diagnosis of high-grade squamous intraepithelial lesion (HSIL, CIN 3).

Correlation between the endometrial sample and the CST showed a discrepancy, given the CST HPV negative result. So, a reflex liquid-based cytology sample was prepared from the CST sample. The cytology showed a single group of atypical cells with HSIL features along with background low-grade squamous intraepithelial changes (Figure 3) and the CST result was amended to HSIL with a recommendation for colposcopic evaluation. This case highlights the importance of thorough evaluation and correlation between all samples submitted for a particular patient. The careful evaluation of the endometrial sample and the recognition of the small amount of admixed abnormal cervical tissue was crucial for the final diagnosis. It was also essential to keep an open mind that, despite the negative CST, this abnormal tissue may reflect a true high-grade cervical pathology. In this case, the pathologist was able to go back and reassess the CST sample via cytology to show concordance between the two specimens. The World Health Organization has recently resolved to adopt a global strategy to eliminate cervical cancer, proposing a threshold of 4 per 100,000 women-years for elimination as a public health problem. Provided vaccination and screening coverage are maintained at their current rate, Australia is on track to becoming the first country in the world to see cervical cancer rates drop below the elimination threshold, estimated to occur by 2035. We, in Australia, must work to build on the successes of our screening program and further reduce cervical cancer. Strong partnership between clinicians and pathologists will remain a key factor in achieving this goal. Author competing interests – nil

Figure 2

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Figure 3

MAY 2021 | 63


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U N D E R N E W M A N A G E M E N T & R E CMEDICAL E N TFORUM LY U PGRADED | WOMEN ’S HEALTH

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CLINICAL UPDATE

Perinatal Depression and Anxiety and breastfeeding support By Caroline Munchenberg, Breastfeeding Counsellor, ABA A complex, bidirectional relationship exists between early cessation of breastfeeding and perinatal depression and anxiety. Hence, it is important for breastfeeding support to be provided to mothers with Perinatal Depression and Anxiety (PNDA), both antenatally and postnatally. The information and support required will vary depending on a mother’s breastfeeding goals, feelings about breastfeeding, their support network, diagnosis, medications, and any breastfeeding problems they have had. Having a positive experience of breastfeeding support has been related to improved maternal psychological health. An individualised approach is vital. Continuing breastfeeding may be beneficial for mothers with PNDA as the breastfeeding hormones, including oxytocin, lower inflammation and the stress response, and promote relaxation and nurturing. Breastfeeding helps mothers sleep, as breastfeeding mothers are more in-sync with their baby’s sleep cycles and this combined with the breastfeeding hormones help mothers fall back to sleep easily after a breastfeed. However, this may not be the case for all mothers with PNDA and, in some cases, having another caregiver or support person available to take the load of other household tasks can enable her to continue with breastfeeding. In very few extreme cases, breastfeedingrelated difficulties may compound the mother’s mental health issues and she may require support transitioning to mixed-feeding or weaning.

Medications, weaning and relactation There are few medications which preclude breastfeeding. Doctors and pharmacists can use their expertise and knowledge of medications to support the mother with combining breastfeeding and any medication she may need for her PNDA. It is important to MEDICAL FORUM | WOMEN ’S HEALTH

Key messages

Receiving breastfeeding support can help a mother with PNDA to overcome breastfeeding difficulties and improve her mental health

Few prescription medications preclude breastfeeding, but PI may offer a cautious approach. There are dedicated prescription medicine helplines in each state

Sometimes breastfeeding does not work out and mothers may need practical and psychological support to wean or even to restart (relactation).

recognise that product information provided by pharmaceutical companies may provide little or no information relating to a medication’s safety in lactation or be legally defensive, hence may err on the side of caution and not provide the full picture to make informed decisions. Other sources about medication and breastfeeding include NPS Medicines Line (1300 633 424), which mothers can be encouraged to phone, and Lactmed, a free online database with information on drugs and lactation aimed at health professionals and the breastfeeding mother. The Australian Breastfeeding Association (ABA) has a useful table listing resources for information about prescription medications and breastfeeding: https://abaprofessional.asn.au/ prescription-medicines-andbreastfeeding While in most cases mothers with PNDA can be supported to continue breastfeeding, in some cases there is need to support mothers with PNDA who have chosen to wean. Some may be looking for permission to wean or some may have already weaned. Different mothers have different emotions around weaning. If a mother finds weaning an emotional experience and her identity as

the one who feeds her baby is important to her, she can be encouraged to ensure bottlefeeding is still a special time for mother and baby and something only she does for her baby. Just because other people can feed a bottle-fed baby does not mean they have to. Conversely, you may encounter a mother who has already weaned but wants support to relactate. This is a reasonable option for mothers even if they are not able to bring back a full milk supply. Any breastmilk they provide for the baby has immunological and nutritional benefits. While the process of relactation takes much dedication and support, mothers whose stories are included in ABA’s Breastfeeding: relactation and induced lactation booklet (2018) describe it at as a fulfilling and healing process. In providing breastfeeding support to the mother with PNDA, it is important to validate her feelings, her opinions, her decisions, wherever she is at that moment even if it seems she is not very well at the time. Encourage and affirm her for seeking support even if she has mentioned something like wanting to use donor milk or choosing to relactate and it seems unusual or unfamiliar. Encourage her to contact the ABA for some breastfeeding counselling around such issues or encourage her to access its website so she can make an informed decision about breastfeeding alongside her recovery from PNDA. Part of the breastfeeding support can include referring expectant and new parents to the ABA, which has many resources. – References available on request Author competing interests – nil

Read this story on mforum.com.au

MAY 2021 | 65


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LIFESTYLE

Painting a picture of remote medicine Royal Perth Hospital resident doctor Lindsay Green reflects on her opportunity to see first-hand the challenges of practising medicine in remote WA.

I was recently fortunate to gain a place in the renowned Community Residency Program offered to junior doctors based at Perth’s three main tertiary centres. The program is sought after because it offers rural and remote experience for a resident term in a number of areas and specialties across Western Australia. I travelled to Derby, once the economic epicentre of the Kimberley in northern WA. The population numbers just over 3000 with nearly 50 per cent identifying as Aboriginal. Trauma resulting from car accidents, alcohol and domestic violence made up most of the patients I treated, followed by complications of diabetes in all shapes and forms such as diabetic foot infections, sepsis, cardiac complications including heart failure, renal failure and more. I was also able to learn about diseases more common in northern WA such as crusted infected scabies and strongyloides. One patient with both diseases also unfortunately had a severe autoimmune condition, which further complicated management.

66 | MAY 2021

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LIFESTYLE

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Remote medicine presents challenges that I believe cannot be fully appreciated and understood from afar. On the whole, referring to tertiary centres was well-received and patients who required transfers were accepted readily and transport facilitated. However, on some occasions it was evident that the doctor receiving the referral had limited experience of the facilities, equipment and the time and effort required to transfer a patient from such a remote location. On one such occasion, I was asked to recontact a specialty only once the patient met certain criteria, which would certainly have meant a worse outcome for the patient given the time and distance they would have been required to travel in that compromised state.

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hospital or missing essential follow-up appointments. Training colleges are moving towards valuing and rewarding remote and rural experience, however, more can still be done. By increasing rural and remote medical student numbers and training pathways, more junior doctors who will one day become consultants will be exposed to the healthcare landscape of the state and the differences that exist. I thoroughly enjoyed my experience in Derby and would highly recommend exploring the Kimberley. My exposure to Aboriginal culture and society has enhanced my understanding and therefore improved my clinical practice when treating and caring for patients of Aboriginal descent.

A considerable number of patients in remote areas will invariably need to travel to a tertiary centre for some form of specialist care, be it surgery, physician review or care in a tertiary centre when unwell.

I fully immersed myself in the experience and was fortunate to win a painting at the famous Norval Gallery Auction held while I was there. Rather aptly, given the opportunity I had to reflect on life in remote Western Australia, the painting was called Contemplation.

At the very least, a basic understanding of the facilities available to the patients and remote healthcare workers will serve to guide and inform the tertiary teams when creating the patient discharge plans, thus reducing the patient number of re-presentations to

Pictures: Dr Lindsay Green shares some of her Kimberley experiences.

MAY 2021 | 67


From pain comes a shared truth A debut novel shining a torch on “women’s problems” touches a raw nerve, as Cathy O’Leary explains.

Perth writer Josephine Taylor’s first foray into historical fiction is a painful one – delving into a chronic gynaecological condition that is experienced by millions of women but still rarely discussed. Eye of a Rook starts in London in the 1860s with a young man, Arthur, struggling to help his wife, Emily, who is suddenly struck down by a pain for which she can find no words and is forced to endure treatments to cure her ‘hysteria’. Meanwhile, in contemporary Perth, writer Alice and her older husband Duncan find their marriage threatened as Alice investigates the history of hysteria, female sexuality and the treatment of the female body – her own and those of women more than a century before. Taylor, a freelance editor and adjunct senior lecturer in writing at Edith Cowan University, uses a hybrid style of writing, combining the fictional stories of the two couples with her own real-life backstory of triumphing over chronic vulvodynia. The condition is thought to affect about 15 per cent of women at some time in their life, and its abrupt arrival in 2000 when she was aged 39 ended Taylor’s career 68 | MAY 2021

as a psychotherapist. She was in so much pain that even sitting in a chair became impossible. After being bedridden for more than two years, Taylor turned to writing to manage her condition, and her research and writing on vulvodynia made its way into her PhD memoir, which was awarded the ECU Faculty Research Medal in 2011, and the Magdalena Prize in Feminist Research in 2012.

Hidden agony “When I had to give up my practice it was because I was in constant agony – people don’t appreciate how severe the pain can be,” she explains. “It was at the level when you can’t really think clearly and I was literally just lying in the loungeroom and watching TV. I couldn’t even read.” In a parallel of her own experience, Eye of a Rook asks the question, what do you do when you have unremitting pelvic pain? Finding a new normal is the answer, Taylor argues, not by 'fixing' it but by developing strategies to live with it. “People ask me ‘are you Alice in the book’ and what I say is that I’ve given her a lot of my experiences but she’s very different to me MEDICAL FORUM | WOMEN ’S HEALTH

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BOOKS


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BOOKS as a person, and I’ve given her experiences other people have told me about,” she says. “But what Alice experiences regarding vulvodynia is very close to my experience in that it started with a urinary tract infection, which didn’t go away, and I was advised to use different creams which made it worse. “For me, it was all the time and everywhere, it was constant generalised pain and every time it was treated the wrong way it would embed even more.”

Recognising signs That is the compelling reason why she wrote the novel because she believes it happens to a lot of women, and they end up with an embedded condition when it did not have to be that way. “The kind of pain Alice feels, like the searing and knife-like pain, is the kind of pain I had, and she found out gradually that it was a sort of pudendal neuralgia – to do with the pudendal nerve – but it’s also a brain problem, a central sensitisation,” Taylor says. “It’s a double whammy. You have centrally mediated pain, which people just don’t understand, and then you have the fact that it’s the genitals and there’s all the hysteria and Freud stuff.” Freud argued hysteria was a psychiatric condition caused by emotional excitability or anxiety, or the unconscious simulation of organic disorders. “Between 10-25 per cent of all women will experience vulvodynia at some time in their life, so it’s millions and millions of women,” Taylor says. “But even now, women reading the book are saying they’ve never heard about it, but that’s because you either have it, and you don’t usually talk about it, or you don’t have it, so you don’t know about it. “At the mild end, a young woman might have discomfort when she inserts a tampon, and sex might be a bit of painful, but she can put up with it, and they’re likely not to say anything.

The male gaze “Some men can be a brutal when it comes to women with this pain but what I’ve found is that many men are very open about genital pain, they seem genuinely interested, and many, including my MEDICAL FORUM | WOMEN ’S HEALTH

husband, are incredibly supportive and don’t doubt what women are experiencing.” Taylor says her condition is more manageable now, and she has learnt what to do and what not to do. “For me, medical intervention isn’t great. Like Alice in the book, I had a pudendal nerve block and it was a disaster,” she says. “But I’ve found that medication is good, and I look after myself on a daily basis. I do particular stretching exercises every morning, and walk and do yoga, and avoid sitting, so I work standing. “If I balance all the parts of my life well, it’s manageable, although there are some things I find difficult to do, like travel. But I’m pretty happy with my life.”

faced with someone in front of them in agony. “We still have a long way to go because women come on Facebook and say ‘they don’t know what the heck’s wrong with me’ or ‘I was told it’s all in my head’ so we still get that reaction surprisingly frequently.

Found wanting “The woman is made to feel that the onus is on her, that there’s a problem with her, rather than it being on the limits of medical knowledge. “I’ve come across some fabulous GPs, but some extra training in this area would be fantastic.” She has particularly welcomed feedback from readers who enjoyed the book but also found it a powerful source of information.

Taylor believes there are gaps in the medical profession’s management of the condition, but it has improved in the last decade and there is a lot more knowledge at the GP level.

“I’m glad it works on both levels, as I wanted to write a good book and a good narrative, but also wanted to affect some kind of change, so if it works on that double level then I’ve achieved what I set out to do.”

“When I first experienced it, nobody seemed to know, and every GP I saw had no idea. Doctors need to be given the opportunity to learn more about it, especially if they’re

ED: Eye of a Rook is published by Fremantle Press.

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LIFESTYLE

In WA we have spent a long time defining ourselves by sport and mining. Perhaps it’s time to recognise ourselves as a State of the Arts as well.

By Ara Jansen For years, arts lovers have been subjected to the endless Monday morning dissections of football. Not that the two things are mutually exclusive, but it’s about time we recognise that Western Australia is also a powerhouse of the arts and should have a piece of the action. It wasn’t all that long ago when WA missed out on numerous arts events – whether it was a big stadium rock show, an interesting collection of paintings or a classical concert. These days we’re done with the Dullsville tag and this year’s Perth Festival, which was almost 100% home grown, was resounding proof we can create art of the highest calibre. When Bourby Webster – an accomplished rower and classical musician – arrived in Perth from the UK some 20 years ago, she discovered that we were “a sporty kind of place, good at digging stuff out of the ground and making lots of people lots of money, we love the beach and ocean and have a vast backyard to explore”. There was no mention of creativity, artistic skill, passion or the word culture. This year, it’s 10 years since she founded the Perth Symphony Orchestra in part to halt the talent drain, show off WA talent and take an orchestra out of the concert hall and into the community. “Today, WA is buzzing with music – and arts in general,” she said. “In other developed cities in the world, the arts are supported in the main either by governments (such as in Germany where some orchestras receive almost 100% funding) or philanthropy (as in the US where arts companies can have at least 150 board members, each donating $US10,000 or more for the privilege). “In Australia we have yet to really see politicians get behind the arts, despite the evidence that shows a positive impact on connected, healthy

continued on Page 72

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WINE REVIEW

Aphelion kissed by the sun I must admit that Aphelion, Greek for “from the sun”, from Willunga in the Maclaren Vale region has not been on my wine radar. Nestled between the hills and the sea, this region, has always produced some fantastic wines due to the moderating effect of the sea. It’s a discovery – Aphelion is producing some stunning wines with traditional techniques and appealing to wine-lovers that like individual, minimal intervention wines.

Review by Dr Martin Buck

Aphelion Welkin 2020 Grenache

Aphelion Affinity 2019 Grenache, Mataro, Shiraz

Aphelion Emergent 2018 Mataro

There is a common theme to the red wines, and it is they are all bright, textural and big on flavour without too much oak in play. The Welkin Grenache is very much a Rhone, lighter style wine with ripe fruit and tarry oak aromas but restrained on the palate. A good acid structure, with some subtle spices and great palate length. A great choice for Grenache lovers like me.

The Affinity GMS is unfined and unfiltered to capture the Rhone delicacy and balance. A complex berry and spice nose with a lighter palate than our typical Australian GSM, nevertheless showing lively fruit, acid and persistence on the palate. A great choice for your favourite gamey dish.

The Emergent Mataro is all about power and finesse. Again, a minimal intervention wine with deliberate minimal use of sulphur, the result is a medium-bodied wine with massive, dark cherry aromas and an incredibly balanced, smooth palate with unobtrusive tannins. The fruit is almost perfumed, lively and kept in check by the great acid balance. My favourite red of the group and highly recommended.

Aphelion Rapture 2017 Grenache, Shiraz, Mouvedre Finally, the 2017 Rapture is the best barrels of the vintage blended as a GSM with Rhone winemaking magic including whole bunch fermentation, cold soaking, minimal intervention and low sulphur. A more full-bodied wine than the Affinity with earthy, lively fruit flavours, clean acid and great palate length. This is the flagship red for Aphelion and very well made. Collectively, the reds show great fruit expression, acidity and balance, the prefect partner for a savoury meat dish – my choice would be a cassoulet and the 2018 Mataro. MEDICAL FORUM | WOMEN ’S HEALTH

S WER' E I V RE

PICK

Aphelion Pir 2020 Chenin Blanc

Pir is made from 50-year-old vines and partially fermented in French oak and left on lees. This is a sensational Chenin Blanc with a velvet smooth, creamy palate, crisp acid and a long textural palate. Winemaker Rob Mack has absolutely nailed this variety and it is a show winner.

MAY 2021 | 71


State of the arts continued from Page 70

Credit: Daniel Carson

communities, innovative thinking and a reduction in mental health problems that cost governments millions. We’re also yet to develop a sophisticated culture of philanthropy.” We are all aware of the physical benefits of being active through sport and recreation, but in recent years a lot more public attention has been given activities that benefit mental health. The arts, in all its many and varied forms, are a wonderful social prescription. For example, music and visual arts are used as therapy in places ranging from prisons and community centres to hospitals and aged care facilities. “The arts are not just about bringing joy and connection – although studies have shown the monster benefits to wellbeing and mental health from the arts – they’re good for the economy,” says Webster. “Our creative industries contributed an estimated $3.3 billion in Industry Value Add (IVA) to the WA economy in 2018-19. There are 53,000 people in the creative workforce and some 10,000 creative businesses in WA, more than 6,500 of them are sole traders.” Webster says, when the arts move in, people and businesses follow. Investing in the arts creates vibrancy, connection, a sense of identity and a unique culture. If WA is indeed now a global arts destination, then the McGowan Government’s election promise of a purposebuilt film and television studio in Fremantle should add to our reputation. As Byron Bay was recently dubbed the new Hollywood, perhaps Perth is the next Canada or the new Georgia – the place everyone goes to actually make their shows. 72 | MAY 2021

If you needed more proof of WA’s love for the arts, even after a packed summer season of arts festivals, local baroque ensemble Australian Baroque has played almost two dozen sold-out shows in recent weeks. The international Concert by Candlelight series arrived in Perth this year and used social media to advertise the one-hour events, which are staged at Winthrop Hall. Organisers chose Australian Baroque to perform Vivaldi’s Four Seasons. Like PSO, Australian Baroque’s efforts to take classical music to the community as seen them playing in more expected venues alongside doing muchloved house concerts, mixing beer and Bach in a brewery and serving cakes with Corelli for Mother’s Day. “In this case, the shows are attracting people who are not your traditional classical audience, which is great for the arts,” says artistic director and violinist Helen Kruger. “They clap between movements or when they like something, stomp and holler during a

standing ovation. People are crying because it’s the first time they’ve heard classical music and have loved it. We’ve even signed some autographs for young kids. “This sort of show gives people another way to engage with classical music and for many, a way they feel more comfortable with. This should help us realise there’s so much scope and potential for how we stage music and how we look at the arts.” “What has held WA back from seeing its arts scene truly flourish is the narrative that we are not into the arts, we’re into sport and mining, so investment and financial support is low,” Webster said. “When people experience us for the first time, that narrative starts to change. We just need to make it appealing and accessible. “I now feel way more positive that our narrative is changing. We’re starting to view ourselves differently. We are recognising that culture is incredibly powerful, whether it’s through cultural diplomacy, tourism, building communities, economic impact or any of the other extraordinary benefits that culture brings.”

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Join our growing network of practices whether you are looking to sell or looking for a practice to join we can help you! Contact Dr Brenda Murrison 0418921073, brenda.murrison@breckenhealth.com.au or Damian Green 0423844268 or damian.green@breckenhealth.com.au


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