Medical Forum – May 2022 – Public Edition

Rethinking breast cancer Women’s Health | Pelvic congestion, heavy menstrual bleeding, telehealth in pregnancy

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EDITORIAL BACK TO CONTENTS

Cathy O’Leary | Editor

The highs and lows of breast cancer More women than ever are surviving breast cancer, and we have clinical trials and improved treatments to thank for that.

When I first began reporting on health – arriving at work in a horse and buggy and using telegrams to contact people – the risk of breast cancer in Australian women was about one in 15.

Today that rate has more than doubled – to one in seven women facing that unwelcome news sometime in their life.

In 2019, breast cancer became the most commonly diagnosed cancer in Australia for the first time, taking over from prostate cancer. More than 20,000 women were diagnosed last year alone.

The increase is thought to be linked to factors including reproductive and hormonal factors, even the environment, as well as improved screening and awareness which are helping to find the disease, often earlier.

And despite the grim numbers, there is a good news story to be told. More women than ever are surviving breast cancer, and we have clinical trials and improved treatments to thank for that.

But as our cover story explains, we can’t ignore the psychological impact of the disease, at the time of diagnosis and even years after treatment.

It was not that long ago that women had to fight to get access to breast reconstruction after a mastectomy because it wasn’t deemed “medically-required”.

All this is a perfect segue to this month’s profile of a stellar clinician working in breast cancer detection, Dr Liz Wylie.

Liz has been at BreastScreen WA for as long as I’ve been writing (she started young too) and I’ve always appreciated the fact that she calls a spade a spade. Read her story – you’ll enjoy her candour and probably have a chuckle.

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

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

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MEDICAL FORUM | WOMEN 'S HEALTH

MAY 2022 | 1

CONTENTS | MAY 2022 – WOMEN'S HEALTH

Inside this issue 24

16 20

12 FEATURES

IN THE NEWS

12 Close-up: BreastScreen

1

Editorial: Highs and lows of breast cancer – Cathy O’Leary

4 6 30 37 43

News & Views

medical director, Dr Liz Wyllie

16 Mindful breast cancer treatment 20 Paediatrician shortage bites 24 Covid impacts clinical trials LIFESTYLE 66 Music soothes a GP’s soul 68 Magic happens all at Once 70 Thumbs up for local film

In brief Handling weighty issues David Prast’s legacy Digital health needed to solve inequality – Luke Baxby

49 Celebrate progress – Dr Joe Kosterich

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CONTENTS

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

Clinicals

ADVERTISING Advertising Manager Andrew Bowyer 0424 883 071 andrew@mforum.com.au Clinical Services Directory Andrew Bowyer 08 9203 5222 andrew@mforum.com.au

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Invasive endocervical adenocarcinoma Dr Jenny Grew

Breast cancer updates Dr Louisa Lo

Heavy menstrual bleeding Dr Mini Zachariah

Lifestyle and fertility Dr Rose McDonnell

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Genomics & reproductive medicine Dr Tamara Hunter

Antenatal telehealth Dr Cliff Neppe

Sinusitis – an update Dr Shane Ling

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Preterm labour & aeromedical retrieval Breeanna Spring Walsh

Pelvic floor exercises during pregnancy Anna Forward

Pelvic Congestion Syndrome Dr Anjana Thottungal

EDITORIAL TEAM Editor Cathy O'Leary 0430 322 066 editor@mforum.com.au Production Editor Jan Hallam 08 9203 5222 jan@mforum.com.au Journalist Eric Martin 08 9203 5222 eric@mforum.com.au Clinical Editor Dr Joe Kosterich 0417 998 697 joe@mforum.com.au GRAPHIC DESIGN Ryan Minchin ryan@mforum.com.au CONTACT MEDICAL FORUM Suite 3/8 Howlett Street, North Perth WA 6006 Phone: Fax: Email:

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Restrictive practices and government over-reach Dr David Roberts

GPs’ role treating incontinence Dr Gina Messiha

Home services boom Julie Adams

Health system needs attention Professor Jaya Dantas

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MEDICAL FORUM | WOMEN 'S HEALTH

MAY 2022 | 3

NEWS & VIEWS

BACK TO CONTENTS

HBF hits pause on gap plans A planned overhaul of payments to doctors

by WA’s biggest health insurer has been put on hold after a strong backlash from the profession.

As revealed in Medical Forum last month, HBF recently announced changes to its gap payment arrangements, with the net result being that some doctors would receive lower fees for their services.

Under the changes – which were due to take effect from July 1 – HBF’s Known Gap arrangements were to be scrapped as well as its excluded items list, which allows a doctor who is a no-gap provider to charge a gap for procedures on that list.

Payments under HBF’s Full Cover arrangements were also due to change, meaning doctors would be paid more for some items and less for others, with anaesthetists, in particular, facing reduced fees.

Since the changes were announced, HBF has been in talks with medical groups and doctors who are affected by payment decreases, including the Australian Society of Anaesthetists and the Australian Medical Association WA. HBF’s director of medical services, Dr Daniel Heredia, has now confirmed to Medical Forum that based

More home visits Silver Chain is working to reduce pressure on GPs and hospitals during the pandemic by providing extra health care services for COVID patients living in residential aged care facilities and private psychiatric hostels in Perth.

Under an agreement with the WA Primary Health Alliance and in consultation with local GPs, Silver Chain will provide face-to-face visits and telehealth services.

Registered nurses will provide care for a range of health conditions including chronic disease care, minor injuries, wound care, and catheter management.

Silver Chain’s Executive Director in WA Renae Lavell said the program would bring care directly to COVID 19-positive patients in residential aged care and private psychiatric hostels and prevent unnecessary hospitalisations due to worsening health conditions.

“By helping to manage the health concerns of a COVID-positive West Australians at the place they live, we can not only relieve some of 4 | MAY 2022

Dr Daniel Heredia

on feedback from doctors and their professional associations, it was pausing the proposed changes to its medical gap arrangements.

“This means that the Full Cover fee schedule will be unchanged on July 1 and the excluded items list will remain in its current form,” he said.

“In addition, the Known Gap arrangement will continue for existing doctors. HBF will continue to consult with the medical profession to find an outcome that best meets the needs of our members and providers.”

the pressure on GPs as COVID-19 cases rise, but also help community members avoid unnecessary hospital admissions,” Ms Lavell said.

New cancer hub for WA A new $750 million comprehensive WA Cancer Centre for cancer treatment, care and research has moved a step closer after receiving a $375 million boost from the Commonwealth Government.

The new centre, which will be developed by the Harry Perkins Institute on the QEII site, will ensure world-first cancer medicines and clinical trials, holistic therapies, an integrated intensive care unit and hospital beds solely for cancer patients will be at the one location.

Perkins director Professor Peter Leedman said the new centre would put WA on the same footing as Victoria with the Peter MacCallum Cancer Centre and

New South Wales with the Chris O’Brien Lifehouse. It will allow WA to be part of a national network of comprehensive cancer centres being developed by the Australian Government’s Cancer Australia agency.

X-rays on the move St John of God Subiaco Hospital has become the first private hospital in WA to install the O-arm system, an innovative orthopaedic surgical imaging device.

The mobile x-ray system provides 360-degree 3D images in real time and can be used before, during and after spinal surgery.

The enhanced imagery improves the surgeon’s visibility of the patient’s anatomy, allowing for better clinical decision-making and surgical accuracy, and ultimately improving patient outcomes.

SJOG Subiaco CEO Professor Shirley Bowen said that by nature spinal surgeries were challenging continued on Page 6

MEDICAL FORUM | WOMEN 'S HEALTH

Supporting women at every stage of life St John of God Subiaco Hospital provides high quality, compassionate and individualised care for women.

This comprehensive care is provided by a multidisciplinary team of gynaecologists, obstetricians, breast surgeons and medical oncologists.

MEDICAL ONCOLOGISTS We put patients’ physical and emotional needs at the centre of our approach to cancer care. Our experienced specialists, who are supported by experienced cancer nursing staff and allied health professionals, explain the patient’s diagnosis and treatment options, and provide comprehensive care to help patients feel supported along their journey.

BREAST Dr Tim Clay

Dr Andrew Dean

Dr Daphne Tsoi

GYNAECOLOGY Dr Martin Buck

Dr Andrew Dean

Dr Tarek Meniawy

BREAST SURGEONS Breast cancer surgery, including Intra-operative Radiation Therapy (IORT), may be a part of patient’s overall cancer treatment plan.

Our world-class specialists have the expertise and understanding to help women feel supported before, during and after their surgery.

Our specialists also offer surgery that can change or improve a person’s appearance for cosmetic or reconstructive purposes.

Dr Helen Ballal Mr Lee Jackson

Dr Corrine Jones Dr Wen Chan Yeow

A/Prof Ming Yew

OBSTETRICIANS/GYNAECOLOGISTS Pregnancy is a special and precious time and our focus is on women and their families. We want patients to feel respected, supported and encouraged throughout their pregnancy and during and after childbirth.

Dr Michael Allen Dr Michael Gannon Dr Adam Gubbay Dr Susan Isdale Dr Fiona Langdon Dr John Love

Dr Althea Magee Dr Seonaid Mulroy Dr Richard Murphy Dr Margo Norman Dr Melissa O’Neill Dr Ana Perkovic

Dr Pierre Smith Dr Joo Teoh Dr Matt Thyer Dr Linda Wong Dr Patrick Wu

GYNAECOLOGISTS Our specialists help women with a range of conditions such as gynaecological cancers, menstrual pain and heavy bleeding, endometriosis, pelvic pain and problems with the pelvic floor.

Dr Jade Acton Dr Fred Busch A/Prof Krish Karthigasu

Dr Todd Ladanchuk Dr Rose McDonnell Dr Roger Perkins

Dr Steven Singh Dr Graeme Thompson

GYNAECOLOGICAL ONCOLOGISTS Dr Raj Mohan Dr Stuart Salfinger

For more information To learn about the expertise and interests of our specialists, visit bit.ly/FaS-Subiaco subiaco.cpd@sjog.org.au MEDICAL FORUM | WOMEN 'S HEALTH

(08) 6462 9689

sjog.org.au/subiacoGPs MAY 2022 | 5

Obstetrics and gynaecology consultant Professor Julie Quinlivan is Curtin University’s new Dean of Medicine. She is a former chair of the Clinical Senate of WA and is current director of the Professional Services Review, responsible for ensuring compliance with MBS and PBS services.

Bronwyn Grant is the inaugural CEO of the Montserrat Group’s Murdoch Private Hospital, which is due to open next year. She has held executive roles in health care for 30 years.

NEWS & VIEWS

continued from Page 4 and complex. The O-arm enabled surgeons to x-ray patients ondemand in theatre.

“As the surgery is more precise, patients can experience less pain and a faster recovery, and the risk of a revision surgery is reduced,” Prof Bowen said.

Heart service milestone Hollywood Private Hospital has notched up more than 250 surgeries through its cardiothoracic service since it opened 18 months ago.

The multi-million-dollar purposebuilt theatre was unveiled at the

Nedlands campus in October 2020.

Since then it has been able to offer potentially life-saving bypass and valve replacement surgeries.

Cardiothoracic surgeon Pragnesh Joshi said the service offered all types of minimally-invasive cardiac and thoracic surgery and the latest technology, including beating heart coronary artery graft surgeries, minimally invasive surgeries for ablation of atrial fibrillation such as hybrid catheter and surgical ablation (HyCASA) and right anterior mini thoracotomy and aortic valve replacement (RAT AVR).

Mr Joshi is the only surgeon in WA performing RAT AVR, which enables continued on Page 8

The Health Consumers’ Council has a new executive director, Suzanna Robertson, who has previously had roles with the WA Primary Health Alliance and the Mental Health Commission.

Drs Stephen Tiang, Mark Teh and Rory McPherson have become partners at Perth Radiological Clinic.

Peter Mott has stepped down as CEO of Hollywood Private Hospital after nine years, replaced by Andrew Tome who moves from Peel Health Campus. Mr Mott will continue with Ramsay Health Care in a more strategic role.

In more hospital changes, St John of God Mt Lawley has appointed former director of nursing and midwifery Vanessa Unwin as its new CEO, taking over from Paul Dyer who is now at the helm at SJOG Midland Public and Private Hospitals.

Telethon Kids Institute and UWA researcher Dr Anya Jones will join some of the world’s brightest scientists on the prestigious Homeward Bound Program. She will travel to Antarctica to see first-hand the impacts of climate change.

6 | MAY 2022

Yarning helps healing In an Australian first, an Edith Cowan University research project has set up community stroke and brain injury support groups for Aboriginal people.

The Brain Injury Yarning Circles project provides a culturally safe space and activities such as a local elders group, swap meets, art, dance, music, men’s and women’s days and excursions to culturally significant destinations.

Project lead Professor Beth Armstrong said previous research identified a gap in the continuity of care of Aboriginal people after a stroke or traumatic brain injury caused by incidents such as a car accident, fall or assault.

“We believe we’ve developed a model for brain injury support groups which can be used to create

similar programs in other areas of the country,” she said.

KM Noongar Consultancy Services director and Noongar woman Kerri Colegate, who runs the Armadale Yarning Circle, said the service was important for participants, particularly those needing to move to Perth for treatment.

“A lot of Aboriginal people have to come off-country for rehabilitation services – and a lot of those people can be alone without their family here,” she said.

“So Yarning Circle was a really good opportunity for those people to come along and connect culturally and help fill that void when they’re missing their family.”

Yarning Circle has weekly events in Armadale which aim to help Aboriginal brain injury survivors and their families. Fortnightly groups in the Mid-West have just started in Mullewa, with Geraldton groups also planned.

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IN BRIEF

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Invasive Endocervical Adenocarcinoma At a recent Clinical Labs Colposcopy Case Review meeting, four of the 15 cases discussed had significant glandular (endocervical) abnormalities including adenocarcinoma in situ (AIS) and one patient with invasive adenocarcinoma of the cervix.

Case Study: Invasive Endocervical Adenocarcinoma KC is a 30-year-old woman on the oral contraceptive pill presented with intermenstrual and post-coital bleeding. The referral cervical screen test was HPV 16 positive and the cytology was negative.

At colposcopy, KC had a type 1 transformation zone, and the impression was of a high-grade squamous lesion. Repeat cytology at colposcopy was negative and a colposcopic biopsy provided a scant sample of mucus and benign endocervical epithelium.

Because of discordance with the colposcopic appearances, a cytology sample was repeated two months later, this time showing features of a possible high-grade endocervical glandular lesion (see Figure 1). The patient underwent a cold-knife cone biopsy which showed widespread involvement of the cervix by invasive adenocarcinoma of usual endocervical

By Dr Jenny Grew Clinical Director of Anatomical Pathology Dr Jenny Grew began pathology training at Christchurch Hospital (NZ), gaining fellowship of the Royal College of Pathologists in 2001. In 2007 she moved to Queensland as head pathologist at QML Pathology. In 2017, Jenny moved to WA and joined Australian Clinical Labs WA as Clinical Director of Anatomical Pathology. She is a keen educator, providing sessions for general practitioners on a range of pathology topics. She is a champion of multi-disciplinary patient care in private pathology and has founded and helped lead several clinico-pathology review meetings in a variety of settings, including private gastroenterology, colposcopy, breast cancer, general surgery, radiology and oncology.

type (see Figure 2). The tumour showed diffuse strong, block-type p16 immunohistochemical staining (see Figure 3), indicating the presence of an integrated high-risk HPV type.

The tumour extended to the deep endocervical and nine o’clock margins. The patient’s case is to be referred for discussion at the KEMH Gynaecological Oncology Tumour teleconference (TCON) for management planning, which surgically is expected to be a radical ovary-sparing hysterectomy.

Screening for Glandular Abnormalities of the Cervix Just as with squamous cancers of the cervix, the majority of endocervical adenocarcinomas are related to oncogenic HPV types 16 and 18.

Most cervical cancers are squamous whilst about 25% are adenocarcinoma. After an initial decrease, the cervical screening program in Australia had little impact on reducing the incidence of adenocarcinoma.

Figure 1

Figure 2

Figure 3

lesions, and interpretation issues in cytology samples. Since endocervical adenocarcinoma is an HPV-related cancer, primary HPV screening enables earlier detection and is more effective than cytology in preventing this cancer.

Eliminating cervical cancer by 2035 Cancer Council data suggests that Australia is set to become the first country in the world to eliminate cervical cancer, provided vaccination and screening coverage are maintained at their current levels.

By 2022, it is predicted that there will be fewer than six cervical cancer cases in 100,000 women, falling into the category of a ‘rare cancer’. That rate is predicted to drop below four cases in 100, 000 by 2035.

The challenge remains to extend these successes to populations still vulnerable to HPV-related diseases, including indigenous communities and low- and middle-income countries.

Reasons for this include the difficulty seeing and sampling glandular

Clinical Labs WA proudly coordinates regular Colposcopy Case Review Meetings to encourage best practice for clinical case review and patient management.

Hosted our Clinical Director of Anatomical Pathology, Dr Jenny Grew, meeting attendance is via video conference and CPD points are available.

If you are a clinician performing colposcopy and would like to be involved, please contact Amanda Reynolds on 0428 921 023 or amanda.reynolds@clinicallabs.com.au

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1300 367 674 | clinicallabs.com.au MEDICAL FORUM | WOMEN 'S HEALTH

MAY 2022 | 7

continued from Page 6 patients to have their aortic valve replaced without an incision on their breastbone, often providing cosmetic benefits and a quicker recovery time.

Hollywood has also become the biggest centre in Australasia for HyCASA.

Funding relief for allergies Allergy experts have welcomed a $27 million Commonwealth investment into allergy prevention and management.

The funding will allow two organisations – the National Allergy Council and National Allergy Centre of Excellence – to work together to deliver new initiatives and research to improve consumer safety and prevent anaphylaxis deaths.

They will aim to cut wait times to see a specialist by at least 50% and improve access to quality allergy care for all Australians, especially those in rural and remote areas.

Dr Preeti Joshi from the Australasian Society of Clinical Immunology and Allergy said the funding would allow urgent research projects to move ahead.

Maria Said, co-chair of the National Allergy Strategy and CEO of Allergy and Anaphylaxis Australia, said Australia had often been termed the ‘allergy capital of the world,’ with more than 5 million people living with allergic disease.

“Allergy diagnoses and hospital admissions for life-threatening allergic reactions continue to rise, and this funding will revolutionise allergy research, clinical care, education and prevention, solidifying us as a world leader in this space,” she said.

Hormones & dementia risk Life events that influence levels of the female hormone oestrogen may be linked to a woman’s risk of developing dementia in later life, according to new research.

The analysis found that some

reproductive events such as early or late start to menstruation, early menopause and hysterectomy were linked to higher risk of dementia.

Having ever been pregnant, having had an abortion and later menopause were linked to lower risk.

Lead author Jessica Gong from Sydney’s The George Institute for Global Health said that although it appeared reproductive events and related hormone changes may be involved in dementia risk in women, the exact relationship was still unknown.

“While the risk of developing dementia increases with age, we don’t yet know whether the higher rates seen in women are simply because they live longer,” Ms Gong said.

“But it’s possible that female-specific reproductive factors may be able to explain some of the sex differences.

The use of oral contraceptive pills was associated with a lower risk of dementia, but the study did not find an association between HRT and dementia risk.

Family charity digs deep for research Support from the philanthropic Sarich family will fund important research at the Perron Institute for Neurological and Translational Science.

Perron CEO Steve Arnott said a generous commitment would help to deliver high quality research, with a focus on translating discoveries into new therapies and clinical processes.

“The funding will enable the institute to continue its research, bringing therapeutic benefits and hope to people with neurological disorders,” he said.

E/Prof Alan Robson, E/Prof Bryant Stokes and Steve Arnott at the announcement.

The main focus of the Sarich family support is the creation of a fund named in recognition of neurosurgeon Emeritus Professor Bryant Stokes for his contribution to the Perron Institute and advancement of neurosciences research.

The Bryant Stokes Neurological Research Fund will support seven projects, up to $100,000 each.

Two other projects have been earmarked for funding from the Sarich family’s contribution.

Improving mental health outcomes in youth is one area targeted initially, with projects such as exploring the potential for tailoring antidepressant treatment based on genetic information about an individual’s drug metabolism.

Research to better understand the pathological relationship between bone and brain will also receive support.

8 | MAY 2022

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NEWS & VIEWS

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Breast cancer updates Breast cancer prevention Prevention of breast cancer is medically possible. In Australia, one in eight women will be diagnosed with breast cancer. In women with moderately (1.5 to 3 times average) and highly (3 times average or greater) increased lifetime risk of breast cancer, personalised risk reducing strategies are available. For example, five years of tamoxifen has been shown, in international studies involving thousands of women, to reduce the relative risk of breast cancer by at least 40% for those who have moderate to high lifetime risk of breast cancer.

This benefit continues for 20 years after completion of Tamoxifen. In some, this benefit is enough to reduce their lifetime breast cancer risk from moderate to average risk.

Tamoxifen is currently available on the PBS, but the uptake is low.

As well as improving the awareness of drug efficacy and availability in Australia, a woman’s breast cancer risk needs to be accurately estimated. This is usually achieved through genetic counselling. We are especially lucky at BCRC-WA to work alongside Bhavya Vora, an associate genetic counsellor.

Hormone positive breast cancer Approximately 70% of breast cancers are hormone positive. Traditionally, women with these breast cancers are recommended adjuvant endocrine treatment +/- chemotherapy to reduce risk of future recurrence and improve probabilities of cancer survival. In premenopausal young women who require adjuvant chemotherapy, adding gonadotrophin releasing hormone (GnRH) agonist, such as goserelin to adjuvant tamoxifen or the aromatase inhibitor Exemestane for five years had been shown to improve both recurrence free and overall survival and is now recommended standard practice in high-risk cases.

• Adding Abemaciclib In women who have high risk early breast cancer, the monarchE study had shown that adding two years of abemaciclib, an oral drug that

Dr Louisa Lo BCRC-WA breast medical oncologist and Education Lead Louisa completed her breast cancer fellowship training at Peter MacCallum Cancer Centre (Petermac) in Melbourne and is completing her PhD in breast cancer liquid biopsy.

She is a principal investigator for breast cancer research studies and has publications in international cancer journals.

Dr Lo would like to thank Dr Hilary Martin and Dr Peter Lau for their contributions to this article.

targets the CDK4/6 protein involved in cell cycling, to adjuvant endocrine treatment has led to a 30.4% reduction in the risk of developing new invasive breast cancer or cancer recurrence. The main side effects of this drug are diarrhoea and clinically insignificant neutropenia. This drug is not currently available on PBS.

trastuzumab-Deruxtecan and small molecule Her2 tyrosine kinase inhibitor Tucatinib is carrying great promise in studies, even in previously heavily pretreated patients with Her2 positive breast cancer and with central nervous system involvement. These drugs are currently unavailable.

• Chemotherapy decisions

Chemotherapy treatment is the mainstay here. It is an area of need as it has a relatively poor prognosis.

Since the CREATE-X study, six months of adjuvant capecitabine, an oral chemotherapy drug is now prescribed as standard practice if there is residual breast cancer after completion of neoadjuvant treatment.

To assist with decision making regarding adjuvant chemotherapy, the breast cancer tissue genomic testing Oncotype DX is available. This test is only useful for cancers up to 5cm with no nodal involvement or, if postmenopausal, with low nodal involvement (1-3 nodes). Unfortunately, Oncotype DX is not currently MBS funded and has an out-of-pocket cost of $5000, with a turn-around testing time of about three weeks.

Her2 positive breast cancer About 15-20% of breast cancers are the Her2 amplified subtype. Adjuvant trastuzumab has been the poster child of targeted therapy in cancer treatments. Recently, antibody drug conjugates such as trastuzumab emtansine, which has been used to treat metastatic breast cancer, is now being used to treat early breast cancer.

Women who needed neoadjuvant treatment for Her2 positive breast cancer will be offered adjuvant trastuzumab emtansine if there is residual invasive disease in the surgical specimen. This has been shown to improve survival rates when compared to using adjuvant trastuzumab alone and is available on PBS.

• Future treatments Antibody drug conjugate

Triple negative breast cancer

• Immunotherapy Adding immunotherapy pembrolizumab to chemotherapy in the neoadjuvant setting had been shown to improve pathological complete response rates from 56% to 63%. In the metastatic setting, adding pembrolizumab to chemotherapy as first line treatment can improve progression free- and overall survival in patients with high PD-L1 expression (CPS>10). These drugs are not currently available on PBS.

• Metastatic cancer Sacituzumab govitecan, an antibody drug conjugate targeting the trophoblast-cell-surface Ag2 (Trop-2) protein has outperformed standard treatment in the landmark ASCENT study even in heavily pretreated patients, regardless of Trop-2 expression. Significant overall survival benefit had been demonstrated and approval has been announced in the Federal Budget for 2022.

PBCI Breast Clinic Suite 404, Level 4, Hollywood Consulting Centre 91 Monash Ave, Nedlands, WA 6009 Healthlink EDI: breastci Telephone: 6500 5576 Fax: 6500 5574 Email: reception@bcrc-wa.com.au www.bcrc-wa.com.au MEDICAL FORUM | WOMEN 'S HEALTH

MAY 2022 | 9

Restrictive practices and government over-reach

By Dr David Roberts, paediatrician, Joondalup

The National Disability Insurance Agency (NDIA) has adopted a controversial policy – The Reduction and Elimination of Restrictive Practices in the Disability Sector.

A restrictive practice was said to be anything that limits a person’s rights or freedoms.

The NDIA puts the argument thus. We ought to protect people with disabilities from violence, abuse, neglect, and exploitation.

Disabled persons have rights that should be respected. Australia is a signatory to the United Nations 2007 Convention on the Rights of Persons with Disabilities.

Originally, a restrictive practice was thought to be seclusion – isolating a disabled person in a place from which they cannot escape; and restraint – restraining a disabled person from freedom of movement.

But the concept has been extended. Restraints are codified as: physical – to forcibly restrict or subdue someone; mechanical – to use a device to restrain someone physically; and chemical – to use a medicine to restrain someone, and other types of control.

In 2014, all Australian governments ratified a national framework in support of the policy, claiming that in Australia violence, abuse, neglect and exploitation are endemic in the care of the disabled. The NDIA cites one study that lends support for this claim.

The NDIS reviewed its activity reports for a six-month period, from July to December 2020. It relied on its definition of a chemical 10 | MAY 2022

restraint. It captured all instances of medication used to modulate behaviour.

And that includes boundaries, rules and sometimes punishments imposed by their parents.

The study uncovered 270,000 such instances; incidents it is claimed were restrictive practices. In the methodology, when a disabled person took an ‘unauthorised medicine’ twice a day for one week, that generated 14 instances of chemical restraint. Thus, it would only take 370 disabled patients taking two medicines twice a day for six months to breach the policy 270,000 times.

To introduce its policy, the NDIS is establishing a complex set of protocols, which it imposes on carers and therapists. Those who don’t comply are threatened with deregistration and as a consequence, will be dismissed.

The disabled person involved will be defunded.

In the case of children, the NDIS Commission gives the following examples of restrictive practices: sending a child to the naughty corner, turning the television off, not allowing your child to go outside and play until they have tidied their bedroom, turning off your teenager’s gaming device, and confiscating your teenager’s mobile phone.

Other examples are sending your child to bed when they don’t want to go, restrictions on the sale of tobacco products to minors, crunch and sip (a Healthway/ Education Department project requiring parents to provide sliced vegetables and water for morning recess).

These are normal parenting practices. Normal children don’t want to go to bed, are sometimes naughty, and watch too much TV. Further, an essential component of the modern approach to disability is the Principle of Normalisation. It has been adopted by the NDIS. It states that disabled children should as far as possible enjoy a normal childhood.

One of the most egregious elements of the proposal is that the NDIS has established a new class of therapist, a behaviour support practitioner (BSP).

All care and therapy funded by NDIS that could involve a restrictive practice must be documented in a behaviour support plan, authored by a BSP. But these people are untrained, unqualified and unregistered in behavioural therapy.

And the NDIS in not a regulatory authority, AHPRA is, and it is yet to give its opinion on this idea.

Finally, the NDIS proposes to amend the Act (the Children Rules) to empower the CEO with the authority to declare that the parents of a disabled child are ‘not suitable’ to make decisions about their own child’s care and treatment. And, for the purposes of NDIS funded services, to replace the parents by nominating another person as the child’s guardian.

And all of the above is going to be administered by the WA Department of Child Protection.

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Earning a charmed existence Radiologist Dr Liz Wylie is passionate – about breast screening, helping women and her garden.

By Ara Jansen “I’m a fat post-menopausal single woman – why should I be ashamed of that?”

Dr Liz Wylie is in a feisty and happy mood. The radiologist is discussing some of her favourite things: helping women through her work as medical director at BreastScreen WA and radiologist at Royal Perth Hospital, her garden, dogs and books.

Liz and her dogs drive south every other weekend to tend her much-loved garden on 3ha on the Blackwood River near Bridgetown. She’s had the property since 1990 and, with a passion for the gardens of England, has set about creating her own version.

The property features a pear orchard and lots of deciduous trees. She describes it as an eclectic Australian ornamental garden with lots of autumn colour, natives, trees and homes for birds. She also has an endless supply of plums and quinces, the latter which she tries to give away to everyone she knows.

After a week of screens and intense focus at work, she loves the physicality of working in the garden, pushing a wheelbarrow, planting bulbs and spending days at a time outside. Keeping her company are her rescue dogs Poppy and Peanut.

“I can feel sore but enriched and really quite happy,” Liz says. “There’s a palpability for me about being outside, so I love being in the garden.”

She’s a big fiction reader and voraciously consumes audio books during the drives south.

“I love the humanity of storytelling. I’m most transported when I’m listening to really good fiction. I have very eclectic tastes but love a good story. My favourite authors are Alan Bennett, Joanna Trollope and Julian Barnes. I also love a good Ruth Rendell or Agatha Christie.

12 | MAY 2022

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“Life is too short and if I’m not consumed by a story, I’ll rip the disc out and fling it across the car.

I won’t listen to anything that’s boring. Sometimes, I’ll get home and the book hasn’t quite finished so I’ll sit in the garage for 20 minutes.”

Once married to a psychiatrist and a mother to two adult children, Liz loves her now single life.

“When I found myself as a single person coming back from Bridgetown in the late afternoon one summer, after not being single for a very long time, I got home and thought ‘is it this wrong to feel this happy? Shouldn’t I be miserable?’.”

Making her mark

Midland – especially after having her plait set on fire on the school bus. Resilience was at the top of the list of high school achievements and she only half-jokingly suggests hand-to-hand combat came a close second.

“I definitely learnt how to look after myself during high school.” Three women in her graduating class in 1974 got accepted into university.

She was the only one who went, the others chose dressmaking and a job as a bank teller.

“I did medicine but I can’t say it was like a noble calling because I didn’t really have much of a clue.

I got good marks but really it has just been serendipitous that I have

had the most charmed professional existence. I’ve had such a fortunate professional life and feel like I was born just at the right time.

“Doing radiology made me realise how an inspiring teacher can have such an influence on you as a student. I remember one of the radiology registrars doing a tutorial for medical students when I was in fifth year at Princess Margaret Hospital. He made it fun and I thought ‘I can do this!’

“Of all the things I did as a student, there were heaps of medicine areas I would rather have had my teeth continued on Page 15

Liz decided in that moment that post-menopause and all, she was going to continue to live a life of meaning, both personally and professionally. She feels like she’s doing exactly that every day at BreastScreen and RPH. The eldest of five children, Liz was born in Sydney, spent her first five years in Darwin and then came to Perth. Her father was an electrical engineer, and her mother became an architect after leaving the army.

“They worshipped education,” she says. “Four of us went to university.

I never thought you could do anything else.”

Liz learnt plenty of life skills during her primary and high schooling in MEDICAL FORUM | WOMEN 'S HEALTH

MAY 2022 | 13

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Earning a charmed existence continued from Page 13 pulled out than do, but the two things which really appealed to me were radiology and psychiatry.”

Liz started as an intern at RPH and did her radiology training there too. Toward the end of her studies, she spent two years in London, which was a strong developmental experience and where she had been doing quite a lot of breast screening. Then the call came from Perth offering her a job back home.

Mentor inspires “I worked with radiologist Turab Chakera, who was like the father of radiology in WA and had a massive influence on the area from the 1970s and well into the 2000s. He passed away in July 2020. I was incredibly lucky to have worked with him. He was an incredible person and an amazing character.”

After London, she returned to RPH in 1990. BreastScreen had started in 1989, she became a consultant for them and never left. She’s been with the free service breast screening group for 32 years, the last 22 of those as medical director.

“In the ’90s I felt like breast imaging and mammograms were like secret women’s business. It wasn’t considered very important and was hard to get people to do it. It was considered the medical imaging equivalent of the last professional resort.

“I love breast imaging and if you have a vigorous and long career, you might stop hundreds if not thousands of women from dying.

It’s not glamorous and you’re not a hero or the rock stars of imaging.

But I do read tens of thousands of mammograms and out of that there will only be 6-7 per 1000 reads with cancer and 994 normal ones. For the women who screen regularly, they are half as likely to die of breast cancer than those who don’t screen.”

While it could always be higher, Liz is also thrilled that the public profile around breast cancer and screenings has risen hugely over the past 30-odd years. She says celebrities like Kylie Minogue, Olivia Newton-John, Cynthia Nixon and MEDICAL FORUM | WOMEN 'S HEALTH

Shannen Doherty have certainly helped keep the issue in the spotlight and remind women to get a regular screen.

“I love the work,” Liz enthuses. “I love the interaction with women – being in a clinic and making small talk and doing procedures as painlessly as possible. It’s also surprising – but heartening – at the level of joy there is amongst the staff and participants in the clinics. It all gives me and the multidisciplinary team a strong sense of purpose.”

Powerhouse team She cites chief radiographer Helen Parry at RPH and Carolyn Madeley at BreastScreen as powerhouses to work with and women who show courageous leadership.

“I get out of bed in the morning because I like the work and I like my peers and co-workers and I love the patients.”

“I come from a family that was strongly iconoclastic and while they taught me to respect authority, I have a healthy scepticism and have been accused of being cynical.”

She’s also excited to have lived through – and continues to be part of – some of the most exciting times of innovation in her field such as the vast improvements in MRI machines, CT, ultrasound and imaging, diagnostic tools and interventions.

“I love breast imaging and if you have a vigorous and long career, you might stop hundreds if not thousands of women from dying.”

“Given where I am in my career, I probably won’t have to deal too much with AI and other disruptors.

Hopefully they will be good at making imaging even more accurate, rather than turning it all into factory imaging. I think I’ve had a charmed professional existence but I do think some parts of this career will be more challenging for my successors.”

MAY 2022 | 15

Reaching out to cancer patients and families With one in seven women affected by breast cancer in their lifetime, there is new focus on the psychological impact of the disease, as Kathy Skantzos explains.

Gone are the days when caring for women with breast cancer, or managing their risk, was confined to a treatment plan of biopsies, surgery and drugs.

Now research is looking at not just the medical management of breast cancer, but also the psychosocial impacts of the disease, to improve the quality of life for patients and their families and that can include trying to understand why some women decide to opt out of the recommended medical treatment.

Locally, Breast Cancer Research Centre-WA’s current clinical trials include GLORIA – a phase 3 study of the Anti-Globo H Vaccine Adagloxad Simolenin in patients with early-stage breast cancer, and DESTINY – a phase 3 active-controlled study of trastuzumab deruxtecan versus trastuzumab emtansine in patients with high-risk primary breast cancer.

But in addition to these trials, BCRC-WA has recently undertaken two new studies looking into the psychosocial impacts of a breast cancer diagnosis – the RAYS (Resilience in Adolescents and Young people) and PACE (Psychosocial Aspects of Choice in Early breast cancer) studies.

BCRC-WA medical oncologist and researcher Dr Peter Lau said the centre was proud of the breadth of clinical trials and studies that aim to understand the needs of patients and their families.

Generational impact Previous BCRC-WA research confirmed high levels of distress in the children of women diagnosed with breast cancer. Among the top unmet needs shared by young people in the study included needing to know more about their mother’s diagnosis and issues around family functioning.

The Resilience in Adolescents and Young people study (RAYS), which got under way last month, has been designed to understand more about the impact of a breast cancer diagnosis on family functioning and on the young offspring of the patient.

“We’re seeing women in their 30s and 40s with young children and that’s not only a potentially devastating diagnosis for the woman but also her family in terms of how they adjust to the diagnosis,” Dr Lau explained.

A breast cancer diagnosis can cause disruption in the family unit when the mother has to undergo surgery or chemotherapy and radiation which can go on for several months.

“All these sorts of treatments can add up to six or eight months so this can really impact upon their families, particularly the young adolescents causing distress for 16 | MAY 2022

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everyone. We are keen to address this,” he said.

“Some of our treatments, particularly chemotherapy, can make women unwell, which is distressing for children to see and feeling they can’t do anything.”

Patients of any Perth Breast Cancer Institute (PBCI) clinician who have children between the ages of 14 and 24 are invited to take part in the study.

Mothers with breast cancer who participate will be asked to complete questionnaires to evaluate their own emotional wellbeing and perceived family functioning. Children who agree to take part will also complete some questionnaires to evaluate their levels of distress and views on family functioning at a visit with an experienced clinical psychologist, along with a parent or support person if appropriate.

“We’ve certainly seen anxiety, depression and real psychological distress from adolescents,” Dr Lau said. “There’s the fear that their mother is going to be sick because of the treatment but also at the back of their minds there’s the fear that their mother might succumb to the disease.

“Sometimes we do see women shield their kids from what’s going MEDICAL FORUM | WOMEN 'S HEALTH

on and I’ve seen it in my practice where they just don’t tell their kids anything and that can create a lot of anxiety amongst the kids if they don’t know what’s going on.”

During the discussion, the clinical psychologist, together with the young person, will identify any unmet needs and what level of further support, if any, is required.

Further intervention may include providing information about breast cancer, community support groups such as CanTeen or community mental health providers, or tailored sessions with BCRC-WA clinical psychologists.

“We can provide psychological support and we also provide information about breast cancer itself, what the diagnosis means and treatments, but also provide psychological support to help them get through this process.

“And we certainly counsel the patient and their families about their risk factors and what testing they can get done.”

About three months after the evaluation and interventions, the mother and the young person will be asked to complete questionnaires to evaluate whether seeking and receiving support has improved levels of distress and perceived family functioning in

both mother and child, and levels of resilience in the young person themselves.

“We’re really excited about this project because this is really an unmet need,” Dr Lau said. “We’re hopeful that we can really improve outcomes for families affected by breast cancer.”

Aspects of choice Dr Lau explained that while most patients are confident in following the advice of their doctors and their medical team, there’s still a small portion of patients who choose not to take the medical advice they’re given.

The Psychosocial Aspects of Choice in Early (PACE) breast cancer study has been designed by clinical psychologists to better understand the reasons why women may decline starting recommended treatment or who stop treatment early.

“PACE seeks to fully understand some of the reasons behind why patients may choose to not accept medical team advice, whether that was a mistrust in doctors or a belief in alternate therapies that they consider to be more effective,” Dr Lau said.

continued on Page 19

MAY 2022 | 17

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Reaching out to cancer patients and families continued from Page 17 Previous studies have shown that the risk of recurrence of a breast cancer event or a breast cancerrelated death was more than six times higher in those who didn’t follow medical advice and complete the recommended treatment compared with those who did.

Understanding the reasons why people may choose not to follow the recommendations of their treatment team and being able to address some of their concerns may lead to better outcomes for these people.

Reasons for not starting or stopping treatment early can include concerns about side effects, lack of confidence in the effectiveness of cancer treatments, lower level of concern about recurrence of cancer, depression, mistrust in doctors or a belief that alternative therapies will be more effective.

“In the age of the internet, social media and misinformation, some patients can have an inherent mistrust of medical advice,” Dr Lau said. “We’ve seen that with certain elements of COVID treatments and COVID vaccines, it can be challenging at times.”

He said there may be a place for complementary therapies and sometimes not undertaking conventional treatment could be a doctor-patient joint decision based on a number of factors.

“While complementary therapies can be used in conjunction with standard medical treatment, and we know that a high portion of our patients choose to do so, it’s just whether they choose to use these therapies in place of standard medical treatment,” Dr Lau said.

“Sometimes joint decisions are made between doctors and patients to forego treatment if the side effects aren’t tolerable and that’s one factor.”

Dr Lau added that cost of treatment could sometimes be a factor, as well as patients listening to external opinions of family and friends.

MEDICAL FORUM | WOMEN 'S HEALTH

“Cost occasionally comes into it, even though the PBS does do a great job of making the treatments affordable, but it’s still a factor in low socio-economic groups,” he said.

“There’s also peer pressure.

Because cancer is so prevalent, everyone knows someone who’s had a cancer and was treated differently, and that can be quite powerful, which is also another factor that can be challenging for clinicians to overcome – reassuring the patient that they trust us in the advice that we give.”

All patients diagnosed with earlystage breast cancer and who are recommended for breast cancer therapy (hormonal therapy, chemotherapy or targeted therapy) by a PBCI clinician are invited to participate.

“If they choose to participate, these patients are then asked questions about their beliefs in medicine, their emotional wellbeing, and whether they intend to use alternative or complementary therapies,” Dr Lau explained.

is their own decision to make.

However, understanding the factors influencing a patient’s decisionmaking enable us to ensure they have all of the knowledge and understanding to make an informed decision.

“A diagnosis of breast cancer is very confronting. Patients are free to make their own decisions about what they feel is appropriate for them.

“We really want to understand how and why patients elect to not follow medical advice and treatment designed to reduce their breast cancer from recurring. Hopefully, with this research, we can improve our communication and establish some early strategies to ensure the best outcomes for our patients.”

Read this story on mforum.com.au

“The final decision about an individual’s cancer treatment MAY 2022 | 19

Paediatrician shortage is biting While many specialists have waiting lists, the shortage of paediatricians in WA is both chronic and acute, with more children with complex conditions needing help.

By Cathy O’Leary

It is not unusual for developmental paediatricians to do their best to keep their name out of the public eye, and even off GP referral lists.

Few have the time to see new patients and their receptionists often have the unpleasant duty of turning away desperate and despairing families. Many of the doctors have closed their books or have waiting lists beyond six months.

Developmental paediatricians, paediatric psychiatrists and general paediatricians are particularly under the pump. A chronic lack of capacity has been compounded in recent months by acute shortfalls, as doctors have been forced into isolation or tested positive for COVID. Others have suffered burn-out and retired early.

Meanwhile, the demand has exploded because of marked increases in children needing assessment and management for autism, attention deficit hyperactivity disorder and mental health problems.

While the problem is not unique to WA – paediatricians are in short supply all around the country – it is cold comfort for parents who are told repeatedly about the importance of early intervention and then are unable to access it.

Six months ago, it was revealed in State Parliament that there was a 16-month wait for a paediatrician and a 10-month wait for a clinical psychologist in the public health system.

20 | MAY 2022

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by Perth paediatrician Dr Lana Bell found that a third of private paediatricians and private child psychiatrists had closed their books completely and another third had their books open but had wait lists of more than six months.

Demand grows Her research also showed that cases were becoming more demanding, with 85% of paediatricians and child psychiatrists reporting an increase in the complexity and acuity of patients presenting.

A similar percentage said they did not think the public system had enough capacity to cope with the numbers and the increase in complexity.

The figures have prompted calls for extra funding for training positions in developmental paediatrics and an increase in developmental paediatrician positions in the public system.

The Royal Australian College of Physicians’ Paediatrics and Child Health Division president Dr Cathy Choong told Medical Forum that the area of major concern was the shortage of general paediatricians and developmental paediatricians.

“In terms of the developmental paediatricians and the general paediatricians, this is happening across Australia, WA is not special, it’s a national concern.” Dr Choong said.

“What is contributing is the greater understanding of the development needs of children, and the diagnosis and understanding of the scope of conditions such as autism has also changed, so the prevalence is no longer one in 100 – it’s probably more like one in 60 in some form.

“It depends on which community you’re looking at but overall throughout the world this particular diagnosis and condition is becoming better recognised.

“So, generally the incidence of developmental conditions including ADHD and autism has risen, and it partly relates to better recognition.”

No shortcuts In terms of what the college could do, the training was 7.5 to eight years in general, allowing for factors such as parental leave. It took a long time to train someone

to manage complex conditions such as developmental or neurodevelopmental disorders.

“There is an accelerated pathway moving forward, so some individuals are able to accomplish this in a shorter period of time, but in general it does take about eight years,” Dr Choong said.

“They have to have a competency around the basic training, to understand the scope of paediatrics and the development of children and adolescents, and then they do their specialist training.

“The shortest possible time to train would be about six years, but a lot of them are slightly extended because they do a dual degree such as general paediatrics and development paediatrics, so the higher degree takes time.”

Dr Choong said there were other reasons, both professional and private, that the training program might be extended. continued on Page 23

Other areas also under pressure were adolescent physicians, who were important, particularly because of the mental health issues as an outcome of COVID.

MEDICAL FORUM | WOMEN 'S HEALTH

MAY 2022 | 21

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Paediatrician shortage is biting continued from Page 21 “There are a number of issues here, and there’s potentially not enough doctors per se across the board, but there is work being done with all the new graduates, especially with the Curtin graduate school, but it doesn’t happen overnight.

“Private sector doctors have certainly been affected by retirements, and that has an impact on access to neurodevelopmental paediatricians because many of those retiring are very accomplished and excellent clinicians. It has put additional pressure on the current circumstances.”

Another factor was that one doctor coming out of training did not necessarily equate to one new person doing full-time clinical work.

clinician-scientist so they will have a portion of their time dedicated to research.”

Dr Choong said the complexity of cases had also increased.

Complex cases “At the upper level, because of the mental health issues that have emerged, that’s a pretty big deal, and not just in infants and the under-fives. Even as they get to secondary school, they can be complex cases with additional mental health components.”

Dr Choong said that newer models of care were emerging, including increased initial assessments with allied health clinicians such as speech therapists and psychologists, and nurse-led protocols.

More doctors, particularly women with families, were choosing not to work full-time, whereas previously when doctors finished their paediatrics degree they worked full-time privately, or a mix of public and private.

“And we should remember that good GPs are part of the care of a child and the family, and that’s very important because some could co-prescribe medication in a collaborative way, and I would anticipate an increasing role for them.

“They’re trained to work one FTE, but when they come out (of training) they might just work 0.6 FTE – it’s a work-life balance issue for them. And some want to be a

“And in the other under-fives, when lots of parents are worried, they should be turning to the child health nurse, because they are some of the most experienced in

Rehab in the home.

terms of development. They’re very proficient in doing some of the initial assessments and surveys, so they’re another important port of call for worried parents.”

Dr Choong said some GPs already worked very well with paediatricians, beginning a lot of the pathways.

But in complex conditions and complex children, even with the help of allied health clinicians, there had to be a central point and the general paediatrician or the developmental paediatrician often took that role.

“That work is still there and can’t be given over, and that’s why their training is so important and any push to try to reduce the time it takes is not going to accomplish what you want from a paediatrician, who might work for 35 to 40 years.

“You want someone who is very well-trained if they’re going to be looking after children, sometimes from the age of two to 18 years.

That’s a big job.”

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MAY 2022 | 23

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Supporting science to find solutions Eric Martin explores how WA’s clinical trials are run and what impact the COVID pandemic has had on drug and treatment development.

While new medicines and treatments are extensively tested in laboratories and in animal studies, to understand how a new drug works in humans it needs to be tested in vitro in a clinical trial.

Clinical trials demonstrate the drug’s safety and efficacy and optimal dosages, the results from which can lead to the development of treatments that can prevent thousands of deaths each year and improve the lives of the many people who suffer from various medical conditions.

Australia currently enjoys a strong international reputation as a destination of choice for clinical trials: in 2019, there were 1,820 ongoing trials in Australia which contributed an estimated $1.1 billion a year to the economy and the industry continues to grow.

Linear, a not-for-profit organisation owned by the Harry Perkins Institute, is a leader in the field, with more than 20,000 clinical trial participants.

Medical Forum spoke with Dr Lara Hatchuel, its associate medical director, about the significance of Australian clinical trials and what impact COVID has had on their operation.

“It does seem slightly unassuming, but there's a lot of benefits to bringing trials to Australia: our diverse population and the fact that we can get slightly more streamlined regulatory approval than in the United States.

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These are drawcards to coming and doing research in Australia,” Dr Hatchuel said.

However, as Linear’s target market has traditionally included backpackers and international students keen to earn some extra cash to fund their time in Australia, COVID has had a significant impact.

“The COVID pandemic has certainly posed a challenge. The travel restrictions have affected volunteer recruitment because we rely on volunteers from across the world, as well as the eastern states,” she said.

Missing backpackers “Travellers would usually have their first stop in Perth, contribute to research, do a fantastic trial and be paid for it, which would fund the rest of their travelling experience.

Since the borders have been closed, we have seen saw a decline in interest.

Another COVID-related challenge has been the need for people to isolate because they have either contracted the virus or been deemed a close contact.

“We're just starting to feel the effects of it now, whereas globally, I can imagine this has been an ongoing problem,” Dr Hatchuel said.

“Yet because clinical trials are so vital to developing safer, more MEDICAL FORUM | WOMEN 'S HEALTH

effective drugs, we are still deemed an essential service and we have never halted operations, which is something we're quite proud of.

“We have really robust COVID policies to safeguard our unit, to protect our staff, and to protect our patients. We have a vulnerable group of people in our unit, which are our oncology patients, and we have taken some great steps to keep COVID out of our unit, and we've been successful to date.”

There has also been a silver lining to the pandemic, with interest in clinical trials increasing alongside social commentary on the approval and rollout of mRNA COVID vaccines such as Pfizer’s Comirnaty and Moderna’s Spikevax.

“On the back of COVID-19 there is a greater awareness of the importance of conducting rapid, high quality clinical trials so that we can develop these breakthroughs for treating patients,” Dr Hatchuel said.

“We've certainly noticed that people are genuinely interested in contributing towards medical research. People apply for many different reasons, but there is a genuine interest now to help

contribute to research, this altruistic wish to be a part of this cause.”

For common good Timothy Roberts, a healthy, semi-retired business owner from Secret Harbour, south of Perth, participated in Linear’s COVID clinical trials early in 2020. He said it was from a genuine concern for his family, after seeing the initial impact of the pandemic unfolding worldwide, that motivated him to volunteer.

“I'd had no experience with medical trials whatsoever except that I knew they went on,” Mr Roberts said. “We've got three boys and they're all in the early stages of their career working in different fields. And I've got an 86-year-old dad who's really the world's oldest teenager – he and my stepmum were about to hop on a cruise.

“At the time, we were getting those horrible scenes out of Italy of people in intensive care, so we encouraged him to cancel the cruise, like many, many people did continued on Page 27

MAY 2022 | 25

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FEATURE

Supporting science to find solutions Alzheimer's, or heart disease and a volunteer might have had someone affected by that disease – that's certainly a motivating factor for them to put their hands up to volunteer,” Dr Hatchuel said.

continued from Page 25 around the world, and then we all went into lockdown.

“For the first time in my life I felt absolutely helpless in terms of anything I could do to make a difference.

“Of course, we get some students, travellers and medical students that are just interested in contributing to science. And, importantly, these volunteers, which we value so much, are compensated for their time while volunteering.”

“I saw the trials on the news, and I thought, that's something I can actually do because up until then, the only thing I could do to contribute was to stay out of other people's way and wash my hands.”

Mr Roberts said that he was surprised by the anti-vaccine sentiments that were beginning to surface within the community, which were largely unheard of before the pandemic.

“Prior to COVID, many people wouldn't think twice about getting a vaccine: just 12 months before that my wife and I had been overseas on a holiday in Africa and we had to take a cocktail of vaccines to get there, and we had to have the equivalent of a vaccine passport,” Mr Roberts said.

“And we didn't think twice about that.”

Mr Roberts was also unperturbed by the prospect of volunteering for a clinical trial at Linear.

“I'm a big fan of the scientific methodology and to take an experimental vaccine that's going through that scientific process, to me it was really low risk,” he said.

“And it was something that I could do, which I felt added value to the fight to get us all back out there doing life.”

Not just COVID While COVID has been a motivating factor for many, there are some who want to be involved for other reasons.

“We might be trialling a drug for a particular form of meningitis, or

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The other cohort of volunteers are those who have a disease or condition that has not responded to existing, conventional treatments in the hope that by participating in a clinical trial they may be part of finding a solution, with a chance of being healed in the process.

“That's something that we're trying to really enhance. It frustrates us that an oncology patient who has exhausted all conventional therapy just doesn't always have access to these lifesaving trials,” Dr Hatchuel said.

Cancer trials “One of our key missions is to effectively link a rare cancer to a trial, so we'd really love physicians to know about the work we do so that the minute they think cancer, they can immediately think, ‘what clinical trial can I put them on?’

“That really is the forefront of medicine, where you're at the cutting-edge and you actually have a good chance of curing something and that's what we're all about.”

Due to the wide variety of trials taking place, they can involve people of all ages, from children to the elderly, and with all types and stages of a disease or condition. continued on Page 29

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MAY 2022 | 27

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Supporting science to find solutions continued from Page 27 While most clinical studies need participants who have the disease or condition that a new intervention targets, healthy volunteers such as Mr Roberts also play a role in supporting the discovery of new treatments and interventions, particularly in early-stage trials.

If someone who is ill is given a medication and then gets better, it could be due to a natural recovery or to other factors. To determine if the intervention has worked, the data needs to be compared to a meaningful benchmark. Hence the concept of the active group and the control group.

All clinical trials have guidelines called inclusion and exclusion criteria that must be met in order to allow someone to take part –both aim to ensure that the trial will produce safe, useful and reliable results.

Before participants join a trial, they

MEDICAL FORUM | WOMEN 'S HEALTH

also need to have tests that allow researchers to evaluate the person's health before starting the trial treatment, so that at the end of the trial, they can tell if there has been an improvement.

More tests are administered during the trial to monitor participants’ health and see whether the treatment is working.

Checks & balances Clinical trials must conform to the Ethical Principles of the Declaration of Helsinki, international Good Clinical Practice guidelines, and in Australia, clinical trials need approval by a Human Research Ethics Committee (HREC) registered with the Australian Government’s National Health and Medical Research Council and must follow the guidelines set by the Therapeutic Goods Administration and Medicines Australia.

standard against which all research involving humans is reviewed, which was developed jointly by the NHMRC together with the Australian Research Council and Universities Australia, in accordance with the National Health and Medical Research Council Act 1992.

In addition, the NHMRC, together with the ARC and Universities Australia, has issued the Australian Code for the Responsible Conduct of Research to guide institutions and researchers in responsible research practices and ensure that their work has integrity and aligns with community expectations.

As part of the process of informed consent, anyone taking part in a trial must be fully informed about the objectives of the research, what is expected of them, and any risks and potential inconveniences that may be experienced – both during and after the trial.

HREC is guided by The National Statement, the Australian ethical

MAY 2022 | 29

Handling weighty issues If you’re trying to help someone who is obese, it seems logical to focus their efforts on losing weight. But, as Cathy O’Leary reports, perhaps that’s not always the best approach.

Sometimes it doesn’t even take words – it can be a glance or a roll of the eyes.

But for the person on the receiving end who is overweight or obese, subtle forms of stigma can be an extra load to carry around.

Curtin University School of Population Health researcher Dr Blake Lawrence does not need any lessons in weight stigma. As a child and teenager who battled with obesity, he can remember feeling constantly on the outer.

It became a personal motivator when he and colleagues decided to review more than 40 studies into weight bias among health care professionals and how it could have a negative impact on people living in larger bodies.

Their review, published in the journal Obesity late last year, confirmed weight bias was found among doctors, nurses, dietitians, psychologists, physiotherapists, occupational therapists, speech pathologists, podiatrists and exercise physiologists.

30 | MAY 2022

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FEATURE

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FEATURE “I was previously somebody living with overweight and obesity, right through my childhood and into adolescent and early adulthood, and can remember distinctly the negative experiences I had in health care settings, and more broadly around the bias and stigma associated with living with it,” Dr Lawrence said.

If health care professionals had a weight bias, it could make them believe the patient was lazy, less likely to follow their medical advice or had a general lack of care about their health. Some studies, he said, suggested that a weight bias could even negatively affect the care provided by the health professional.

WA’s Health Consumers’ Council has also been active in this area, working with the WA Health Department and the WA Primary Health Alliance – as part of the WA Healthy Weight Action Plan – to unpack how attitudes can alienate people who are overweight.

Weight of numbers The need for change is clear, with two-thirds of adults and a quarter of children in WA considered overweight or obese.

WAPHA is developing a healthy weight general practice clinical content working group to find better ways to engage with patients, while the HCC recently held an online community forum.

The HCC argues obesity is a

complex chronic condition with genetic, environmental, physiological and behavioural determinants. Yet the causes of obesity are often oversimplified to focus only on a person’s behaviours around food choices, levels of exercise or knowledge of nutrition.

In other words, it is easier to label someone who is overweight as lazy, lacking in willpower or noncompliant.

HCC deputy director Clare Mullen said that despite the prevalence of overweight and obesity in WA, it was difficult to talk about, and how people responded was very individual.

While some people were happy to discuss their weight and might even want it to be raised, others found it unhelpful and sometimes harmful.

“One of our consumers who has a daughter with a health condition that makes managing her weight difficult talks about how when she sees health professionals it’s always doom and gloom because her daughter hasn’t lost weight,” she said.

More than weight

Blake as a teen

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“The mother says it’s not just that health professionals want to focus on her daughter’s weight, it’s the fact that she can’t get them to focus on anything else.

“The professionals might argue there’s no point talking about x, y, z until you lose the weight, but the person might already be doing a lot to try to lose weight and they’re not sure what else they can really do.”

Ms Mullen said there was a lot of emerging science around weight health, and while many health professionals believed weight management was part of their scope of practice, very few had specialist training in it.

“Because we all eat and move, many people get a lot of advice from their family and friends – along the lines of ‘have you tried this or that’.

I’m not a clinician but having worked in health services for a while, I feel that the more I discover the less I know.”

She said some literature argued that humans were driven to eat a certain amount of protein, and because a lot of it was now wrapped up in ultra-processed foods, our bodies could be fooled into thinking we were getting protein when in fact we were just consuming more carbs and sugars.

And that’s just one strand of the research – there were other factors

continued on Page 33

MAY 2022 | 31

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FEATURE

Handling weighty issues continued from Page 31 such as hormones, and the links between mental health and weight gain.

Missing the mark That was why glib advice to “just lose weight” often did not hit the mark.

“There seems to be a series of biological mechanisms and we’re still at the bottom of the mountain in understanding them,” Ms Mullen said.

“And some consumers who have been living with obesity since they were children still carry the memories of being bullied at school.

“People in larger bodies say it’s sometimes the non-verbal things, but sometimes it’s the glance, and possibly it’s not even within that health professional’s awareness, but they’re rolling their eyes or looking at you in a funny way.”

When seeing a doctor, perhaps

the blood pressure cuff is not big enough for someone’s arm, or the scales do not go above 100kg.

“Much of their life they’re being told, either directly or indirectly, that they don’t fit. Take a chair, some don’t want to sit on it because they’re not confident it won’t break it, or the chair might have arms on it and they couldn’t fit anyway.”

Away from health services, overweight people faced negative attitudes on a daily basis, down to name calling in the street.

“I get so angry because it’s like the last bastion of acceptable prejudice that people can say these comments out loud,” Ms Mullen said.

“And while with some health conditions you can meet other people with the same thing and share experiences, the way we’ve been socialised into thinking about being overweight or obese is to say, “at least I’m not as bad as them” so there is this comparative and internalised stigma.”

Ms Mullen said people with weight issues were not homogenous. The experience of someone who might have hovered most of their life between healthy weight and being overweight and then in middle age had some weight creep on was very different to that of someone who was 150kg and had lived with that for a long time.

“That’s why it’s important we have health professionals who firstly understand enough about the science and secondly have the time and empathy to come to the conversation genuinely interested in finding out what’s going on for that person.

Being overweight might be a filter – not the underlying issue.

“And you need a health professional who will stick with it as long as you, because it can be very tiring trying to do it on your own,” she said.

“And what we’ve also heard from consumers is ‘if you’re going to continued on Page 35

Start by asking The “5 As” model involves a step-by-step framework for realistic and sustainable weight management, with a focus on improving health and wellbeing.

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Handling weighty issues continued from Page 33 tell me I’m overweight, I’m kind of hoping that you’re going to be able to help me do that’ because most people don’t need a clinician to tell them that they’re overweight.

“What they might need help with is understanding their actual risk.

For someone with a family history of diabetes, weight loss might be particularly important because there are significant health issues, so that might mean looking at weight loss surgery.”

Ms Mullen said that she started looking at this issue back in 2018, HCC did a survey of consumers about weight issues and it really struck a chord.

“Some of the stories were awful – people who had struggled with weight problems for years and just wanted help, but nothing worked,” she said.

“We’re immersed in this idea of

personal responsibility and if you’re in that situation of being overweight, it’s entirely your own fault. And not only is it your own fault, it’s because you’re lazy and you don’t look after yourself.”

Weight not the end-all It was also wrong to assume everyone viewed being heavy as a bad thing.

“Some people might have a body size that puts them in the overweight or obese category, but health and weight is not an issue for them, and then you have others for whom it’s been a major struggle,” she said.

“Consumers want to be asked what it is they have tried and what they think works for them. People think they’re being helpful telling them they should lose weight – but as if that person has never thought or tried to lose weight.”

equals bad’ and promote a more nuanced discussion.

The way people viewed nutrition and eating was affected by many factors, such as grandparents’ attitudes to food and whether or not as children they were told to eat everything on their plate regardless.

“My concern is that if people are making an effort and taking measures to lose weight such as good nutrition and activity, but they don’t in fact lose weight, are they going to potentially stop those behaviours that are still good for them?

“For some people losing weight is never going to be an easy thing, and the motivation required to change habits is significant.

“But I’m excited that there is increasing awareness about weight stigma and its impact.”

Ms Mullen said there was a push to change the narrative that ‘fat

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NEWS

Life-changing moment changes many lives A surfing accident at a Perth beach more than 25 years ago led to a life committed to help others, as Cathy O’Leary explains

During a quick dip at Cottesloe Beach on a calm February afternoon in 1995, a seemingly innocuous accident while body surfing changed a young man’s life in an instant.

David Prast sustained a highlevel spinal injury that would leave the 29-year-old a C5-6 complete quadriplegic and shape a new direction in his life as he campaigned to find a cure for spinal cord injury.

After many months in hospital, David suddenly had to negotiate life in a wheelchair, with limited hand movement and paralysis from the chest down.

He went on to campaign governments to shift more funding to research and lobbied the WA Government to set up Australia’s first Neurotrauma Research Program, directing funds from traffic fines into research to help people in road accidents who were left with spinal cord and brain injuries.

David was also involved in setting up the Spinal Cord Injury Network, and helped to introduce a model of exercise rehabilitation to Australia and promote pioneering research which led to some spinal injured people gaining movement.

Legacy put to paper Now, 10 years after David’s death, his work, which saw him rub shoulders with top researchers in spinal cord injury and the late actor Christopher Reeve, has been internationally recognised in a book.

Walk On – The Remarkable Life of David Prast was written by Peter Murray, who worked with people with spinal cord injuries and was inspired by David’s story.

There are over 20,000 Australians with spinal cord injuries, which are largely incurable and cost the MEDICAL FORUM | WOMEN 'S HEALTH

economy $3.7 billion a year.

Spinal Cord Injuries Australia said David revolutionised the way people with spinal cord injuries were treated, by bringing together Walk On – now called NeuroMoves – a specialised exercise and therapy service designed to help people maximise their functional ability and lead to a more independent life.

Making moves NeuroMoves now has 11 centres across Australia and more than 700 weekly clients, providing people with intensive exercise therapy after an accident.

SpinalCure Australia executive director Duncan Wallace said David understood that getting clinicians and scientists collaborating was

the key to getting the necessary medical evidence.

“He would be truly excited to see NeuroMoves being part of the next leap in spinal cord injury treatment,” Mr Wallace said. “We are now launching Project Spark and our eWalk trial which build on the NeuroMoves service by combining it with spinal cord neurostimulation.”

In his 16 years as a quadriplegic, David initiated projects to find a cure for paralysis, including stem cell research, and was the driving force behind setting up research programs and conferences in Australia and overseas.

He remained a major advocate for people with spinal injuries until his death in 2011.

MAY 2022 | 37

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GUEST COLUMN

GPs’ vital role treating urinary incontinence Wembley Downs GP Dr Gina Messiha says doctors need to think outside the square when it comes to treating urinary incontinence.

Urinary incontinence (UI) is a common problem, estimated to affect one in four Australians, and the most common types are urge, stress or mixed incontinence.

But UI is under reported, under screened and under treated. As a result, many people are suffering in silence, not only affecting their quality of life, but also significantly impacting their psychological and emotional wellbeing that can have major economic consequences.

It’s a condition that stands alone or is often associated with a wide range of medical conditions, lifestyle, and environmental factors.

The Continence Foundation of Australia has identified some staggering statistics. By 2030, more than 6.2 million Australians will be living with incontinence, and 80% of people in the community with UI are women.

double, from 129,000 in 2010 to more than 250,000 in 2030.

In the 2020 annual survey by the National Association for Continence, more than 40% of people with bladder leakage waited two or more years after their symptoms first appeared before seeking help from their doctor.

As GPs, we have an important role to identify any patients at risk, and provide treatments and follow-up of patients with UI. However, there’s a lot of uncertainty and debate around how involved or well UI is being managed by GPs.

More options

Almost half of the people with incontinence are under the age of 50, and one in three women experience leakage postpregnancy.

While some patients receive effective care, others report suboptimal care and high referral rates to specialists. A recent survey showed that only 50% of primary care physicians talked about the treatment options available with absorbent products and medications as the most recommended, without any other alternatives.

Untreated, the number of people in residential aged care living with incontinence is expected to almost

Traditionally there are many common options as the first line of treatment.

Medication is effective, however, as with all prescribed medication, efficacy and side effects must be discussed and may not be suitable after assessment.

Lifestyle changes such as losing weight, reducing alcohol and caffeine, limiting fluid intake and constipation management can help.

Vaginal electrical stimulation can be useful, but it can come with higher risk of adverse effects such as infection, pain and burns.

Bladder training, pelvic floor muscle training (PFMT) or Kegel exercises have been shown to be effective when performed correctly.

The combination of medication, lifestyle modification, and bladder training in conjunction with effective PFMT has been proven successful and is best recommended before considering the invasive option of surgery.

But while PFMT has been recognised as effective, it can be quite harmful if performed incorrectly.

Those who have any pelvic floor muscle weakness or dysfunction are less likely to perform effective PFMT even after trained instructions from the physiotherapist.

Pelvic floor woes Over 30% of women with urinary incontinence are unable to identify and activate the levator ani muscles of the pelvic floor when instructed to perform, and instead mistakenly contract their diaphragm, abdominal, gluteal muscles, or hip adductor muscles. It’s also hard to motivate patients into maintaining this routine for a minimal three months.

continued on Page 40

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MAY 2022 | 39

GPs’ vital role treating urinary incontinence continued from Page 39 New research has found that highintensity, focused electromagnetic (HIFEM) technology is an option that can non-invasively treat UI. The HIFEM energy is distributed through a chair-like device where the patient sits fully clothed, receiving a 28-minute treatment.

The energy stimulates the entire pelvic floor muscle region by depolarising the motor neurons to generate 11,000 supramaximal contractions in a single session.

These supramaximal contractions bypass the central nervous system and sustain the muscles at a much longer and higher tension strength than maximal voluntary contractions.

It can be a key factor towards restoring the neuromuscular control of the pelvic floor muscle and educates patients on how to selectively contract these to

40 | MAY 2022

maintain muscle tone and longterm function.

New options Since implementing HIFEM into my own practice as the foundation tool prior to PFMT, this new approach has bridged the gap and many challenges from the conventional methods.

I had an 87-year-old female patient with severe mixed UI. At baseline assessment she was using six pads a day, four pads a night, and would get up at least three times during the night with fully soaked pads.

Selective anticholinergics didn’t work, and guided physiotherapy made no difference. Post-HIFEM treatment, her improvements reduced to two pads/day (only damp), one pad/night and getting up only once during the night.

my less severe patients, there was a significant improvement with no leakage upon assessment and marked improvement of the pelvic floor muscle tone reported from the physiotherapist.

PFMT has long been recognised as the gold standard solution to UI problems, but recent studies have now shown that HIFEM can improve the pelvic floor integrity.

It can help patients to regain strength in their pelvic floor muscles, enabling them to achieve better health outcomes and avoid further problems and complications down the line such as bladder control, organ prolapse, pain and discomfort and sexual dysfunction.

I took her off Vesicare and the results were maintained at two months review with an addition of topical estrogen therapy. For

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GUEST COLUMN

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GUEST COLUMN

Pandemic sees rise in home services Delivering chemotherapy at home makes even more sense during a pandemic, argues Julie Adams.

As COVID-19 has moved through our community and restrictions around gatherings, masks and vaccination requirements have eased, there is one group of patients whose level of anxiety has increased – the immunocompromised.

They are a heterogenous group, largely comprising those with autoimmune diseases such as multiple sclerosis, colitis and rheumatic conditions, and those undergoing cancer treatment.

Many are on immunomodulating medications such as immunotherapy or chemotherapy.

View Health chemo@home is a home-based service safely providing chemotherapy and

immunotherapy to patients with cancer and chronic illnesses, which has has many advantages including reduced travel, parking, decreased costs, improved patient and carer convenience, and an enhanced patient experience.

With agreements in place with all the major private health insurers (HBF, Medibank, BUPA, HCF, AHSA funds), a number of contracts with pharmaceutical companies and other arrangements for patients not otherwise covered by these funding options, the service has quickly expanded across Australia.

A great example of how chemo@ home collaborated with health care organisations was demonstrated in 2020 when it was approached

by Royal Adelaide Hospital to develop and implement a plan to protect cancer patients by rapidly transitioning them from the dayunit to home-based treatment.

The organisation successfully transitioned 600 treatments. This model has now been presented at a national oncology conference and has published in the Australian Health Review.

After the recent and long-awaited opening of the WA border, COVID positive cases numbers have increased rapidly and, along with that, referrals to the service have increased by 25% in a month.

Using telehealth, medical consults continued on Page 43

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MAY 2022 | 41

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Genea Hollywood Fertility Level 2, 190 Cambridge Street, Wembley WA 6014 p (08) 9389 4200 w wa.genea.com.au 42 | MAY 2022

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GUEST COLUMN

Digital health needed to solve inequality The digital transformation of our health system must benefit all Australians, argues Luke Baxby.

Our health system and front-line workers have stood tall in the fight against COVID, supported by what was already a world-class health system.

But the focus on COVID has masked an underlying trend which can upend our quality of healthcare and severely damage Federal and state and territory budgets.

Technology, well designed, can save the day.

According to recent analysis in Australia’s Health Reimagined white paper, produced by Deloitte in collaboration with the Consumers Health Forum and Curtin University’s Digital Health Collaborative Research Centre, we must act now.

In the short term, state and federal governments can manage the expected short-term surge in demand for health care was by rapidly deploying telehealth. Not as a one-off, but as a core and systemic part of delivering health care.

Starting by levering existing investments in digital health infrastructure like telehealth and e-prescription services, we must then make greater use of health data sharing and digital health monitoring technology.

As we saw through COVID, telehealth was embraced by citizens: telehealth services grew from less than 1% of Medicare consultations pre-COVID to more than 25%, adding capacity during a time of high demand.

As this technology is adopted, the healthcare system can focus more on at-home and preventative care, reducing rates of chronic disease and the administrative burden on our healthcare workers.

Not only is health demand unsustainably on the rise, but we also now confront a changing burden of disease, and despite the talk of Closing the Gap, we really haven’t shifted the dial on health outcomes of Indigenous Australians.

By 2050, the proportion of our population aged over 65 will increase from 6% to 22%. Our modelling shows that to meet that demand, our healthcare workforce must become five times more productive – an impossible task.

Health inequality will put an additional strain on our hospitals when so much of this could be avoided. Worse, unaddressed, health inequality will entrench social and economic disadvantages for too many Australians.

From an infrastructure perspective, our modelling of public and private hospital bed requirements to 2035 suggests Australia will need to build a 375 acute hospital beds every month for the next 15 years to keep pace with demand and replace ageing stock.

But a reform effort around digitisation can make big inroads into meeting our challenges – of driving better access, improving efficiency, and better connecting and integrating our health care into a system built around the needs of our citizens.

However, digitisation cannot be an end in itself. Our approach to this must keep the needs of all Australians in mind. Otherwise, those who stand the most to gain from a more robust health system – the lower income, the elderly and the disabled – could be stranded by a digital divide.

There is such much to be gained in a digitally powered health system.

Without the reform zeal now, our health system will be overrun, and the quality of healthcare will diminish. As we embark on this, let’s be clear that digitisation needs to be for all, not the lucky majority.

ED: Luke Baxby is Deloitte Australia National Healthcare Lead.

Pandemic sees rise in home services continued from Page 41 and home-based services have given immunocompromised patients the comfort they need to be able to continue with their medical care without further compromising their health.

Additional benefits to home-based treatment have also come to light during the pandemic, including higher levels of patient support and MEDICAL FORUM | WOMEN 'S HEALTH

education through the one-on-one nursing interaction, and reduced patient and visitor traffic in hospitals.

The increased patient support and education is particularly pertinent for vulnerable patients who have been largely denied the opportunity of having a loved one accompany them to their appointments and treatment in health care facilities. It is unlikely that the trend towards home-based

services is likely to abate. Once patients are aware that services such as ours are a safe option, well-supported by more than 1500 specialists Australia-wide, their desire to attend a hospital day-unit diminishes.

ED: Julie Adams is managing director of chemo@home and was the 2016 Telstra Western Australian Business Woman of the Year

MAY 2022 | 43

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GUEST COLUMN

Our health system needs attention Our ailing health system needs urgent treatment, argues Curtin University’s Professor Jaya Dantas.

Well after the start of the SARSCOV2 pandemic in December 2019, WA has experienced some of the harshest border closures in the world and a policy of zero COVID and no community transmission for most of 2020 and 2021.

Since last December, we have had mask mandates, social distancing, border closures, mask-wearing and a successful vaccine rollout. WA, along with most parts of Australia and the world, is currently impacted by the Omicron outbreak and its high transmissibility.

However, even with a spike in the number of infections, many countries felt it was time to remove most public health restrictions and have a plan of ‘living with the virus’ to provide people with a sense of normality.

Slow motion In WA, there has been a reluctance to open up, with the border opening pushed back until early March this year, and we still have a state of emergency, which will continue for the next few months.

The government has continued with mask-wearing for children from Year 3 onwards and all adults, even though we have some of the highest vaccination rates in the world of people who are double dosed (97%) or triple dosed (78%).

One of the constant messages used by our government has been the fragility of the health system – that our hospitals will not be able to cope and the health workforce is chronically understaffed. This has been perplexing, given we have had 24 months to be prepared and a budget surplus of $5 billion in 2021.

The past few years, even before the pandemic, have highlighted a health system in crisis – the hospital system, the Indigenous health system, the aged and disability care system and the mental health system.

MEDICAL FORUM | WOMEN 'S HEALTH

Ambulance ramping has been a feature of our public hospitals, as have a lack of beds, breakdowns in ICT systems and a chronic shortage of clinical, nursing and support staff.

The Electronic Medical Record System has still to be rolled out across our public and private hospitals. The crisis at the Perth Children’s Hospital has been reviewed after the death of a child in 2021.

We have also seen the challenges of the mental health system with access to prevention support impossible, with wait times of four to five months to see a psychologist or psychiatrist, not enough beds except for the most acute cases and not enough community support.

No amount of funding can reduce a crisis of the kind we have if we do not have professional staff to support the system. There needs to be access to communitybased services, along with better integration of behavioural health services and transitional housing services.

Navigating the complexities of the aged care and disability care is a minefield for even the most tenacious. We know that more Australians are choosing to stay in their homes as long as possible, so we need a balance between residential and home care.

Currently the business model means that providers have control, and the emphasis is on profit. This model disempowers families and the clients (the aged or disabled) who often do not have a say in the outcomes they want or need.

Under investment All of these factors indicate a chronic under-investment in the total health system over a period of time. For a healthy society we need sustained and continuous funding that meets ever-changing needs for growth and improvement.

The strongest indicator of health outcomes are the social determinants of health – the economic, educational, environmental, housing, transport and social contexts that people live and work in. These determinants are responsible for the variation in health disparities and outcomes and the pandemic has highlighted these in our communities.

We need robust systems to collect high-quality data that includes comprehensive information on the social determinants, and includes components of housing, finances, nutrition and food security and transport, and variables that can measure structural racism in our health system.

Whole of government We also need models that can meet our health-related community social needs. The government needs to engage across multiple departments so that health departments and clinicians collaborate with public housing departments, aged care and disability agencies and Indigenous organisations.

As a society we have a collective responsibility for health. The government has an obligation to create social processes where people are empowered to take up this responsibility.

While the WA Sustainable Health Review of 2019 considered these factors and reports on progress, it is harder to understand from the reports how efficiently funds are allocated to ensure a high level of service delivery that ultimately benefits the consumer.

Governments must not abdicate their responsibility to provide health care and ensure health resources are distributed fairly to reduce social differences in health.

ED: Professor Jaya Dantas is from Curtin University’s School of Population Health

MAY 2022 | 45

46 | MAY 2022 42 | SEPTEMBER 2020

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MAY 2022 | 47 SEPTEMBER 2020 | 43

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OPINION BACK TO CONTENTS

Dr Joe Kosterich | Clinical Editor

Celebrate progress and aim for more Despite enormous progress in the last half century, medicine tends to be a glass half empty type of profession. We focus on what is wrong and shrug off what is good. This is not to say that all is perfect or that we cannot aim to do better, but this is not mutually exclusive with pausing to acknowledge what has been achieved.

The impact of lockdowns and school closure will have disproportionately affected women.

For unknown reasons this has not been talked about.

Women’s health is an area where significant progress has been made.

A cursory glance at the survival rates from breast cancer and cervical cancer tell a tale of vastly improved treatments coupled with better detection.

Women have lower rates of smoking and alcohol addiction than men.

Life expectancy is longer for women.

All this does not mean we sit on our laurels. It is a foundation for further improvements.

This month we have articles on differing aspects of women’s health.

Pelvic congestion is a diagnosis many may not be that familiar with but can significantly impact quality of life. Pelvic floor exercises are generally recommended after rather than during pregnancy – we may need to think again.

Better ways of preventing preterm birth, especially in remote areas, have been the subject of research and this is covered, as are simple lifestyle measures that can improve fertility, and use of telehealth in antenatal care. Heavy menstrual bleeding remains a common problem and is examined. Genomics is a Pandora’s box which has been opened before we quite know how to manage it. For a change of pace, sinus issues are also looked at.

Women still tend to do more child-rearing and the number of single mothers dwarfs that of single fathers. The impact of lockdowns and school closure will have disproportionately affected women. For unknown reasons this has not been talked about. Hopefully the impacts will be studied, and lessons learned.

One matter to ponder. When asked the question “can you define what a woman is” neither the Federal Health Department secretary or US Supreme court judge Kentaji Brown-Jackson would or could answer.

The latter used the excuse that she wasn’t a biologist. I am not a mechanic but can define what a car is. Yes, the question was asked for political reasons, but nevertheless, if we can no longer define a woman, how can we further improve women’s health?

MEDICAL FORUM | WOMEN 'S HEALTH

MAY 2022 | 49

Heavy menstrual bleeding

By Mini Zachariah, Gynaecologist, Nedlands Abnormal uterine bleeding (AUB) is common and refers to uterine bleeding of abnormal quantity, duration, or schedule.

Based on current terminology, heavy menstrual bleeding (HMB; regular bleeding that is heavy or prolonged) refers only to cyclic (ovulatory) menses.

In a research setting, heavy menstrual bleeding is objectively defined as a total menstrual blood loss of at least 80ml per menstruation. A more practical definition is excessive menstrual blood loss significantly impacting a woman’s quality of life or resulting in iron deficiency.

Evaluation and management All patients with AUB need a complete history and physical examination. A thorough menstrual history (duration, and volume of AUB, presence of associated symptoms, precipitating factors, and medications) is the single most useful evaluation tool. A pelvic examination can give important clues about causative factors.

Pregnancy should be excluded.

50 | MAY 2022

Key messages Heavy menstrual blood loss is common A thorough evaluation is critical to identify the cause Medical or surgical treatments are available, and the choice is influenced by multiple factors.

Investigations include up-to-date cervical screening test, full blood count, serum iron studies and a transvaginal pelvic ultrasound scan with coagulation studies and thyroid function if indicated.

Endometrial sampling should be performed in nonpregnant patients with any bleeding pattern if obesity or other risk factors for endometrial hyperplasia or cancer are present.

Treat HMB when it interferes with quality of life or causes anaemia.

Factors influencing treatment choices include the aetiology, severity of bleeding, associated symptoms such as pelvic pain, infertility, contraceptive needs and

plans for future pregnancy, medical comorbidities, underlying risk for venous thromboembolic disease and/or arterial thrombotic events and patient preferences.

Treat the primary aetiology if possible. This includes endocrine or infectious disorders treated medically (e.g., polycystic ovarian syndrome, chronic endometritis) and structural lesions resectable via hysteroscopy (endometrial polyp, submucosal fibroid).

Treatments Antifibrinolytic agents and NSAIDs are first line agents, used only during periods. Tranexamic acid represents an option for treatment of patients with HMB who are trying to conceive and those who do not desire or should not use hormonal treatment. A 25-40% reduction in blood loss is reported.

There is no evidence that longterm use of antifibrinolytics during periods increase the risk of venous thrombosis.

Combined oral contraceptives and the Progesterone only Pill

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CLINICAL UPDATE

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CLINICAL UPDATE (Drospiredone) reduce blood loss by 50-53%. The Levonorgestrelreleasing intrauterine system (LNG IUS) results in a reduction of menstrual bleeding of up to 80% at six months and over 90% by 12 months.

The choice of surgical therapy depends on the patient's characteristics, therapeutic goals and fertility plans.

Pathophysiology – the FIGO PALM-COEIN classification system STRUCTURAL ABNORMALITIES

NON-STRUCTURAL ABNORMALITIES

P - Polyps

C - Coagulopathy

A - Adenomyosis

O – Ovulatory dysfunction

L - Leiomyoma

E – Endometrial

M – Malignancy and Hyperplasia

I – Iatrogenic N – Not otherwise classified

Myomectomy (for fibroids) is the only fertility-preserving surgical option. For patients with intracavitary fibroids, hysteroscopic myomectomy may reduce bleeding and also improve fertility. For patients who do not desire future fertility, a minimally invasive option may be appropriate (e.g., endometrial ablation or uterine artery embolisation). Hysterectomy is appropriate for patients who have failed other surgical treatments and/or who desire definitive treatment.

Pregnancy is contraindicated after endometrial ablation with effective contraception necessary in sexually active women. Endometrial ablation and the LNG IUS have equivalent efficacy in reducing menstrual blood flow in patients with HMB. In women with HMB and associated dysmenorrhoea in the context of adenomyosis endometrial ablation may result in less patient satisfaction. Progestin-based treatments can address both HMB and dysmenorrhea.

Endometrial ablation is a minimally invasive option suitable for women who have completed childbearing when medical therapy fails or those not wanting chronic medical therapy.

Endometrial hyperplasia/ malignancy should be ruled out by biopsy prior to performing ablation.

Women with significant risk factors for endometrial cancer (obesity,

MEDICAL OPTIONS Non-hormonal: 1. Antifibrinolytic agents –Tranexamic Acid; 1gram QID for 5 days starting on D1 2. Non-steroidal anti-inflammatory drugs (NSAIDs) Hormonal: 1. Combined Oral Contraceptive Pill 2. Progesterone only options: a. Progesterone only Pill – Slinda - Drospiredone b. Intra-uterine device – Mirena, Kyleena - Levonorgestrel c. Depo-Provera – Medroxy Progesterone Acetate d. Cyclical oral progesterone Eg: Provera, Norethisterone (additional contraception needed) e. Mini Pill – Levonorgesterel - Not highly effective f. Implanon – Etonogestrel - Not highly effective Rarely used medical options: 1. Androgenic anti-oestrogens (Danazol, Gestrinone) 2. Non-androgenic anti-oestrogens (Tamoxifen) 3. GnRH agonists SURGICAL OPTIONS 1. Surgical treatment of the aetiology a. Hysteroscopic resection of polyps, intracavity/submucous fibroids b. Myomectomy if indicated – selected cases only 2. Conservative surgical management of HMB a. Endometrial ablation b. Uterine artery embolisation

anovulatory bleeding, or a history of breast cancer or tamoxifen use) should be counselled regarding the potential diagnostic challenges and delay in diagnosing post ablation endometrial carcinoma (PAEC).

In these instances, alternative treatment modalities particularly Progestin-based treatments such as LNG – IUS must be offered and strongly recommended for their HMB as these agents reduces the risk of endometrial hyperplasia/ cancer.

Uterine artery embolisation is an option for patients with uterine leiomyomas. The safety of pregnancy after this procedure has not been established, therefore, it is usually reserved for patients not contemplating future childbearing.

Hysterectomy represents definitive treatment for uterine bleeding. This procedure has a high rate of patient satisfaction because it is curative, is frequently performed after medical management has failed, is not associated with drug-related side effects, and does not require repeated procedures or prolonged follow-up.

Hysterectomy has a risk of perioperative complications and, depending on the operative approach, a prolonged recovery.

Gynaecologist referral is appropriate for patients with heavy bleeding, severe anaemia, persistent bleeding despite treatment, suspicion of malignancy, or if surgery is required.

Gynaecology referral is also appropriate if the primary care clinician is not comfortable performing endometrial sampling or placing an intrauterine device for treatment of AUB. – References available on request Author competing interests – nil

3. Definitive surgical management a. Hysterectomy

MEDICAL FORUM | WOMEN 'S HEALTH

MAY 2022 | 51

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52 | APRIL 2021

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CLINICAL UPDATE

Lifestyle and fertility

By Dr Rose McDonnell, Obstetrician and Gynaecologist, Claremont One in six couples suffer infertility, defined as the inability to conceive a pregnancy after 12 months of unprotected sexual intercourse.

Infertility is attributed to male and female factors including ovulatory disorders, ageing, endometriosis, fallopian tube damage, uterine fibroids, autoimmune disorders plus lifestyle and environmental factors including geographical challenges such as fly-in-fly-out working.

Diet and exercise A healthy body mass index is beneficial for fertility. A BMI below 18 or above 25 may impact fertility by interfering with hormonal and metabolic mechanisms.

Increased abdominal fat distribution reduces ovulation and reduces the chance of conception even when ovulation occurs. BMI above 30 is associated with a halving in spontaneous conception rates and exacerbation of the adverse metabolic and reproductive issues seen in women with polycystic ovarian syndrome (PCOS).

Endocrine abnormalities and lower testosterone rates are also seen in obese men, as is erectile dysfunction, which can impact on coital frequency and semen parameters.

Obesity contributes to poorer outcomes with IVF including lower rates of pregnancy and higher rates of miscarriage. Obesity in pregnancy increases the risk of gestational diabetes, hypertensive disorders in pregnancy, preterm birth, fetal macrosomia, and higher rates of caesarean section.

The child’s health is also impacted.

Obesity increases rates of congenital anomalies (e.g. neural tube defects, orofacial clefts, cardiovascular anomalies), and childhood obesity. Weight loss medications and insulin sensitising agents as well as bariatric surgery have been used by women attempting to lose weight to improve reproductive outcomes. Early dietician, exercise MEDICAL FORUM | WOMEN 'S HEALTH

physiologists and psychologist review should be encouraged.

A diet rich in antioxidants, fibre, folate, fruit and vegetables for both men and women can improve fertility. Women with higher monounsaturated to trans-fat ratio, vegetable over animal protein, highfat over low-fat dairy, a decreased glycaemic load, and an increased intake of iron and multivitamins had lower rates of infertility due to ovulation disorders.

Advise a folic acid supplement (minimum 400mcg daily) to reduce neural tube defects risk and avoid heavy seafood consumption due to the negative impact of high mercury levels on fertility. For men specifically, excess levels of oxidative free radicals can affect sperm motility and DNA damage and a diet low in fat and high in protein has been shown to improve overall health, enhancing fertility.

Moderate physical activity positively impacts fertility by

optimising energy balance in the body and improves physical wellbeing and mood. Excessive exercise may result in low levels of leptin secretion from adipocytes as a consequence of reduced energy intake or excessive energy use. This down regulates the hypothalamic pituitary ovarian axis, which controls ovulation.

It is essential to take a history from women with lower body mass indexes to determine whether amenorrhoea or oligomenorrhoea may be due to this phenomenon as a reduction in energy expenditure and relaxation of any rigid dietary restrictions in place may aid in resumption of normal ovulation.

Creating new coping strategies for women who rely on exercise for stress management may aid in long-term stress management and the creation of alternate methods to manage stress. Encourage continued on Page 54

MAY 2022 | 53

CLINICAL UPDATE

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Genomics: the future of reproductive medicine

By Dr Tamara Hunter, Fertility Specialist, West Perth The Human Genome Project (completed 2003) has given us the ability to read the complete genetic blueprint for a human being. Genomic medicine has rapidly advanced and been applied to many aspects of care including reproductive medicine.

For over a decade the safety and efficacy of Preimplantation Genetic Testing (PGT) of embryos has been researched and debated. This encompasses testing for monogenic/singlegene abnormalities (PGT-M), for chromosomal structural rearrangements such as translocations (PGT-SR) and for aneuploidy of embryos (PGT-A).

These are now well accepted techniques in ART. Advancements in testing and reduced cost has led to the evolution of applications of genomics to preconception screening and ultimately embryo profiling for future disease that perhaps warrant further review.

Expanded carrier screening Preconception carrier screening refers to the process of identifying individuals/couples seeking pregnancy who would be at risk of

transmitting autosomal recessive (AR) or X-linked genetic disorders to their offspring (e.g., cystic fibrosis). Carrier individuals are not aware of their status unless screened.

child born with a condition).

Reproductive couples where both are carriers for a specific gene mutation have a 25% chance of a child being born with the condition associated with the gene mutation.

The ideal time to assess carrier status is before conception so that all options can be considered (preimplantation genetic testing of embryos created using IVF, egg/ sperm donation, amniocentesis, preparation for managing a

Historically, carrier screening for select disorders has been offered to specific ethnic groups (e.g., Ashkenazi Jewish populations) due to the high frequency of carriage of gene mutations. However, studies using patient-reported ethnicity

Lifestyle and fertility continued from Page 53 moderately strenuous activities (e.g. pilates, yoga, walking, swimming) three to four times a week.

Substances Smoking negatively impacts fertility in men and women. Women who smoke are twice as likely to have infertility and the impact is dose dependent even in women who are passive smokers. Oocytes and sperm are susceptible to the effects of cadmium and cotinine found in cigarettes.

54 | MAY 2022

Tetrahydrocannabinol (THC) found in cannabis has also found to decrease gonadotropin-releasing hormone (GnRH) secretion by the hypothalamus with concomitant decreases in folliculogenesis, ovulation and sperm maturation and function. Heroin, cocaine, and abuse of codeine also reduce reproductive performance.

Direct links between alcohol consumption and testicular atrophy, decreased libido and decreased sperm count have been demonstrated.

Key messages One in six couples suffer infertility Many lifestyle factors impact fertility and can be improved Age is an overlooked modifiable factor.

It is thought that alcohol affects female reproductive function by reducing estrogen levels, which reduce FSH and suppress both folliculogenesis and ovulation. The amount of alcohol that impacts on reproductive function is difficult to ascertain and abstaining when trying for a pregnancy is recommended.

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CLINICAL UPDATE

Key messages Genomic applications have evolved Availability has preceded Medicare funding There are numerous philosophical issues.

and whole genome sequencing have determined there is much greater variation in true ethnicity and therefore presumed carrier status frequency.

Expanded carrier screening (ECS) offered universally to all patients/ couples planning a family is the suggested option.

ECS proponents cite the ethical principles of justice and reproductive autonomy, and international evidence suggests that it will reduce public health burden. Being offered by commercial laboratories before Medicare funding may preclude many from access. Other potential harms have been proposed such as the impact of introducing ECS in donor programs and the potential discrimination that may be construed by those living with medical conditions resulting from gene mutations.

there are multiple panels of gene mutations on offer. Along with ethnicity-based screening, RANZCOG endorses universal screening for cystic fibrosis, spinomuscular atrophy (SMA) and Fragile X. Beyond this, there are no consistent society guidelines.

Most agree on excluding from panels those genes that have adult onset or those with large phenotypic variability making prognosis difficult to predict.

Currently it lies with the referring clinician, often the GP, to provide both pre- and post-test counselling on ECS and some would argue on the suitability of this.

MacKenzie’s Mission (research at Harry Perkins) will hopefully go some way to answering these questions.

Polygenic Embryo Screening Polygenic Risk Scores (PRSs) were developed using genomewide genetic data and imputation methods to identify an individual’s risk of disease. There is growing research into the application of PRSs to adult health to identify and manage those at heightened risk for common late-onset diseases (e.g., coronary artery disease, breast cancer).

There is remarkable variability among the commercial laboratories and even within the same lab

Polygenic embryo screening (PES) applies PRSs to IVF embryos and there is much debate over its appearance in clinical practice despite relatively little empirical research. Due to the ‘eurocentricity’ of the genome-wide association studies from which PRSs are

Alcohol consumption in women has been associated with earlier menopause due to accelerated follicular depletion, increased time to conception, reduction in conception rates by 50%, reduced implantation and increased risk of miscarriage and fetal death.

pregnancy outcomes such as miscarriage, stillbirth, low birth weight, childhood acute leukaemia and childhood overweight and obesity. Current evidence supports advising pregnant women and women contemplating pregnancy to avoid caffeine.

Consumption of 500mg (over five cups of coffee a day) has been associated with decreased fertility in women. Two to three cups of coffee per day (200-300mg) may increase miscarriage risk but has not been shown to increase the risk of congenital anomalies.

Environmental (specifically endocrine-disrupting) chemicals can alter hormonal function of men and women. Advise avoidance of exposure to polychlorinated biphenyls and strongly encourage use of personal protective equipment when exposed to pesticides or chemicals. Limiting exposures to personal care products and air pollution can improve female fertility.

Which gene mutations should be included in ECS panels offered to patients?

Recent findings showed maternal caffeine consumption is reliably associated with major negative MEDICAL FORUM | WOMEN 'S HEALTH

generated, these scores are less accurate in individuals of nonEuropean ancestry.

Additionally, studies by companies marketing PES have been done using sibling pairs discordant for selected disorders, not comparing multiple related individuals with unknown patterns of disease which is more akin to the IVF scenario.

PES is being marketed as a screening tool for multiple common polygenic diseases simultaneously.

Whereas PGT-M or PGT-A enables parents a clear ‘implant vs discard’ dichotomous decision, PES users will have to balance risk of multiple conditions when deciding to use an embryo (e.g., one embryo 30% risk T2DM but minimal risk Alzheimer’s disease, another 3% T2DM risk but 20% risk of Alzheimer’s disease by 75 years).

Many questions need answering – who should provide the preand post-test counselling on this screening tool, what are the ethical implications for individuals and societies, what conditions should be included and how does this impact on public health?

Unfortunately, it is even more of an evidence free area and as PES is already on offer in the clinical space, it is incumbent on key stakeholders to urgently address guidance and governance of PES. – References available on request Author competing interests – nil

Perhaps the most modifiable factor is the age at which a couple consider trying for a pregnancy.

Fertility declines with increasing age of both the man and woman, but the effects are greater in women.

The age-related decline in pregnancy and live birth is coupled with an increased risk of aneuploidy and miscarriage. Semen parameters in men decline after the age of 35 and offspring born to men over 40 have increased risks of birth defects, schizophrenia, and cancer.

– References available on request Author competing interests – nil

MAY 2022 | 55

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CLINICAL UPDATE

Antenatal telehealth – providing new insights into antenatal care

By Dr Cliff Neppe, Obstetrician-Gynaecologist, Joondalup De Nicola et al. defines telehealth “as the technology-enhanced health care framework that includes novel services such as virtual visits, remote patient monitoring and mobile apps or text messaging that uses both synchronous and asynchronous communication.” This broad definition provides a promising foundation for adapting the maternity care delivery model to the needs of the 21st century.

The COVID-19 pandemic has demonstrated a strong need for engaging with patients remotely.

Telehealth use has increased 38fold from a pre-COVID baseline.

From an initial spike of more than 32% of office visits via telehealth in April 2020, to a stable 13-17% utilisation across all specialties The pandemic coupled with millennials (born between 1981 and 1996 – ages 24-39 in 2020) becoming the majority (83% in 2020 Australia) of women giving birth have challenged standard antenatal care that requires a change in approach. This generation expects convenience in health care services and telehealth is an important component of delivering it.

Attendance at in-person childbirth education classes has dropped as millennials have turned to friends, family, social media, and the internet for much of their childbirth education needs. Digital tools for patient education as part of antenatal telehealth, are another component well suited for this technology savvy generation.

The digital health ecosystem, combining a broad variety of communication channels including both synchronous (video, voice) and asynchronous (chat, online messaging, email) modalities, facilitates continuous communication between expectant mothers and health care providers.

Depression (prenatal and postpartum) and pregnancy related anxiety are common but neglected MEDICAL FORUM | WOMEN 'S HEALTH

complications of maternity care.

Antenatal telehealth has the potential to improve screening for perinatal mood disorders and provides a channel for early intervention.

The use of antenatal educational materials delivered at the appropriate stage of pregnancy, together with self-measurements of fetal heart rate (FHR), BP and other vital signs, empowers the expectant mother increasing her knowledge, engagement, and self-efficacy.

Early detection of complications through self-monitoring at increased frequency compared to standard prenatal care and timely response on part of health care professionals are important components of telehealth interventions and are expected to improve the clinical outcomes of maternity care.

Although telemedicine and integrated digital health platforms have improved many areas of health care, there has been slow uptake for pregnancy care because of concerns about the safety of home fetal monitoring. Over the past 18 months, we have shown that a novel, maternally administered fetal heart rate monitor (FHRM) has accuracy and safety equivalent to gold-standard clinic-based cardiotocography.

Connected Maternity Care a hybrid virtual (30% of antenatal consultations +1 postnatal consultation) / in-person consultation will be implemented from 2022 to 2024, enrolling 7,500 women attending the Joondalup Health Campus antenatal clinic.

The model will use and evaluate a digital platform integrating home monitoring, telehealth consultations, curated education, midwife support, and appointment scheduling delivered via a smartphone application. We will collect data on maternal physical and mental health outcomes, fetal and neonatal outcomes, user compliance and satisfaction,

adverse outcomes, cost, and service efficacies. These will be compared with data from 2021 (pre-implementation) using independent-samples t-tests or Mann-Whitney U-tests for nonnormally distributed variables This model has advanced analytic tools assessing patient information predicting adverse health outcomes.

The project evaluation report will analyse the impact of this model on delivering antenatal care for pregnant women and their babies regarding health (including mental health) outcomes, patient satisfaction and empowerment, and time and cost savings. Modelling will be used to estimate the relative risk/benefit compared to traditional antenatal care.

We will evaluate the impact on health care providers, looking at satisfaction, system usability, time, and cost savings.

This model uses a combination of synchronous real-time consultations, asynchronous “store and forward technology”, and remote monitoring modalities. Data is presented to the clinical team with customised alerts to flag abnormal results.

The Connected Maternity Care model has three main components: a digital platform for home monitoring, hybrid virtual/inperson consultations and curated education.

The source of the “standard” schedule of antenatal care in Australia, consisting of routine, inperson, antenatal visits (every four weeks until 28 weeks’ gestation, every two weeks until 36 weeks, and weekly until delivery), is a 1929 policy statement from the United Kingdom, still followed almost 100 years later.

In 2022 we are looking to shake up the standard schedule of maternity care to Connected Maternity Care.

References available on request Author competing interests – the author is involved with the research described

MAY 2022 | 57

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CLINICAL UPDATE

Sinusitis – an update

By Dr Shane Ling, ENT surgeon, Carine Sinusitis, one of the most common presentations to primary care clinics, affects children and adults.

A combination of appropriate medical therapies, and at times sinus surgery, may be needed.

Functional endoscopic sinus surgery is safe and well tolerated, playing an important part of disease management and symptom improvement. Emerging biologic agents may become available for patients with recalcitrant sinusitis and nasal polyps.

Sinusitis is characterised by the cardinal symptoms of nasal obstruction or congestion and nasal discharge (rhinorrhoea or post-nasal drip) with associated symptoms of facial pressure or pain and reduction or loss of smell. If the symptoms are present for less than 10 days, then this is considered the viral common cold. Acute post-viral rhinosinusitis is present if the symptoms persist for up to 12 weeks.

Treatment is still largely supportive with intranasal corticosteroid sprays, saline irrigations and simple analgesia. Antibiotics are best reserved for acute bacterial rhinosinusitis and can be suspected if three of the five symptoms are present: fever >38oC, severe local pain or becoming unilateral, double worsening or raised ESR/CRP. Recurrent episodes should be an alert to potential underlying issues and justify ENT referral.

Structural issues within the sinonasal cavity are a common association reducing ventilation and obstructing drainage. Examples include nasal septal deviations, nasal polyps, turbinate hypertrophy, and anatomical variations of the pneumatisation of the sinuses.

An important secondary cause is odontogenic infections or following dental procedures.

Medical conditions worth considering are allergic rhinitis, vasculitis, immunodeficiency syndromes and cystic fibrosis.

The common theme is impairment of mucociliary clearance MEDICAL FORUM | WOMEN 'S HEALTH

Key messages Sinusitis is defined by cardinal symptoms of nasal obstruction, congestion, and nasal discharge.

Treatment mainstay for chronic rhinosinusitis is intranasal steroid sprays and saline nasal irrigations, and specialist referral when symptoms are significant Endoscopic sinus surgery plays an important role in helping to control symptoms and allowing for better penetration of topical therapies. mechanisms. Smoking is a risk factor and cessation strategies are important to discuss. Asthma has a high association with recurrent symptoms and repeat sinus surgery.

Chronic rhinosinusitis (CRS) is defined when these same symptoms persist beyond 12 weeks, with associated endoscopic findings of mucosal oedema, mucopus and polyps and/or CT findings of mucosal changes within the drainage pathways of the sinuses. The previously mentioned structural and medical risk factors play a part in the aetiology. Asthma and smoking are highly correlated with CRS. Many environmental and host factors contribute to CRS developing, with each patient having their own individual combination. The mucosa serves as a barrier interacting with the immune system and also modulates the level of inflammation.

In CRS, this is breached, and chronic inflammation begins, with tissue remodelling and clinical symptoms. In difficult-to-treat cases, the focus has shifted to the type of inflammatory response CRS patients exhibit, and it is becoming clear that the more resistant patients exhibit Type 2 inflammatory responses characterised by IL-4, IL-5 and IL-13.

CT sinus scans are the gold standard for imaging. X-rays are no

longer indicated. Unilateral findings warrant prompt specialist referral to exclude secondary causes.

The main stay of treatment is intranasal corticosteroids and saline irrigation. A brief course of antibiotics or oral corticosteroids may be considered to try and achieve symptom control. If the symptoms remain clinically significant, despite regular use of these medical therapies, referral to an ENT surgeon is appropriate.

Patients have individual needs, but if patients have trialled regular management for eight weeks without relief, then endoscopic sinus surgery can be considered to help gain control of symptoms.

The surgery is conducted using high resolution video endoscopic systems, with equipment specifically designed for sinus surgery. Anatomical variations (e.g. septal deviations turbinate hypertrophy) are addressed, any polyps are removed and the sinus cavities are opened.

The degree and extent of surgery is stepwise, and more radical surgery such as opening of the frontal and sphenoid sinuses can be offered. Surgery and medical therapy should be considered as an integrated care model, where surgery allows for better penetration of local therapies as well as relieving patients symptoms.

Unfortunately, there is a risk of recurrence of symptoms, especially in nasal polyps. Further surgery can be performed without compromising safety or increasing morbidity.

Our understanding of the inflammation pathways in sinusitis has now expanded our treatment to include biologic therapies, such as dupilumab (anti-IL-4 and IL-13) and omalizumab (anti-IgE). The patients who might benefit are those with severe disease or recurrent nasal polyps, who remain symptomatic despite appropriate medical therapies and extensive endoscopic sinus surgery.

Author competing interests - nil MAY 2022 | 59

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CLINICAL UPDATE

Threatened preterm labour and aeromedical retrieval

By Breeanna Spring Walsh, Research Officer, RFDS, RN, RM, PHDc The leading cause of pregnancy related aeromedical retrievals from remote Australia is threatened preterm labour.

Women in remote regions have difficulties accessing pregnancy, birth and postpartum care as specialised health services are mainly metrocentric. Around 8% of all Australian births are premature, but preterm birth rates are near 13% in remote communities.

When it comes to threatened premature labour, Salbutamol, which stimulates the beta 2 receptors in the uterus causing the muscles to relax, can halt contractions. It is a drug option used on threatened preterm labour starting between 22 and 37 weeks of pregnancy.

Research is limited, providing clinicians evidence-based guidance on the emergency, transient inflight use of Salbutamol to provide a bridging gap to prevent remote and inflight birth. In aeromedical care, flight crew aim to keep babies inutero in transit, until transfer to an obstetric centre.

Remote preterm births are complex, nerve wracking and at times suboptimal, with many remote health care centres lacking very early newborn specialists, equipment, and medications.

Evidence shows very early gestation babies, born away from large obstetric centres tend to have worse health outcomes. In very early gestation labours, remote birth is linked to higher rates of cerebral palsy and poor health outcomes (e.g., chronic illness, developmental delay, psychiatric illness).

Though pausing labour seems counterintuitive, in-utero, intransit care optimises lifelong health outcomes for the baby.

At the referral centre and during emergency flight, steroid and magnesium medication are typically given to improve the baby’s health outcomes. These medications stabilise the early fetus ready for birth. Their actions include preventing breathing difficulties and brain injuries.

MEDICAL FORUM | WOMEN 'S HEALTH

Key messages Rural, remote, low SES and ATSI women have near double the rate of preterm birth than that of urban women In utero aeromedical transfer of women in early labour improves newborn outcomes Preterm birth is linked to lifelong disability. Remote preterm birth exacerbates morbidity and mortality.

We recently conducted research aimed at learning whether the drug Nifedipine alone, or a combination of Salbutamol and Nifedipine was best to enable in-utero aeromedical evacuation of women in threatened preterm labour throughout remote WA to King Edward Memorial Hospital.

Nifedipine works by preventing calcium from moving into the muscle cells of the uterus, making it less able to contract. Nifedipine can be less effective than Salbutamol in halting a threatened preterm labour (particularly in established progressing labour) but has fewer secondary effects. Thus, Nifedipine is the first line drug of choice to halt threatened preterm labour rather than Salbutamol.

We reviewed 236 women in early labour aeromedically retrieved throughout WA between the years 2013 and 2018. The average maternal age was 27.9 years. Cervical dilatation ranged from closed to fully dilated in flight. The average cervical dilatation was 0.9cm before the flight. 147 women had at least one comorbidity, with the leading being substance use disorders which affected over 20% (n=31) of the women transferred. Nearly 10% (n=20) of the women flown had bleeding (antepartum haemorrhage).

The gestations of pregnancy started from 22+6 weeks.

Rheumatic Heart Disease (RHD) is widespread throughout Northern Australia, which impacts threatened preterm labour management.

Clinicians are reluctant to give

Lifelong outcomes are improved by threatened preterm labour management in aeromedical retrieval to specialised centres.

Salbutamol to women with RHD in threatened preterm labour because of concerns for the impact to the mother’s heart.

We only captured two women with RHD who were in threatened preterm labour and neither received Salbutamol. We feel this requires further research.

Early, remote births could be reduced with the use of Salbutamol, if deemed safe for emergency, transient therapeutic use. We found the combination of Salbutamol with Nifedipine significantly improved effective labour halting, to enable the emergency flight.

Side effects of this drug combination included the mother having a high resting heart rate (greater than 100beats per minute) nausea and vomiting, with their babies also having high heart rates (greater than 160beats per minute).

We determined these transient side effects outweighed the alternative of a remote early birth, linked with serious life-long disabilities.

Author competing interests – the author was involved with the research described.

Research acknowledgements – Edith Cowan University, the Royal Flying Doctor Service of Australia and Professor Fergus W Gardiner.

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CLINICAL UPDATE

Pelvic floor exercises during pregnancy: a help or hindrance?

By Anna Forward, Physiotherapist, Subiaco For many pregnant women, the logistics of passing a baby through the pelvis during birth can seem very daunting. It can seem a conflicting message when they are told to do pelvic floor muscle exercises to ‘strengthen and tighten’ the muscles they want to easily pass a baby through.

Understandably, confusion or lack of clarity around pelvic floor muscle exercises during pregnancy is a common hurdle to their uptake.

Key messages Antenatal pelvic floor exercises assist birth and reduce the risk of urinary incontinence in late pregnancy and early postpartum.

Perineal massage during pregnancy can also assist birth.

Women may be apprehensive to uptake these interventions without further information and guidance. A Pelvic Health Physiotherapist can assist.

We as health professionals can help to clear a few things up.

Firstly, the evidence busts the myth that pelvic floor exercises hinder birth, and we can confidently reassure our patients that doing them will not have negative effects on delivery and birth outcomes.

According to a recent systematic review and meta-analysis there was no significant difference in normal vaginal birth, caesarean section, instrumental birth, and episiotomy rate when pelvic floor muscles exercises had been completed during pregnancy.

In contrast, antenatal pelvic floor muscle exercises have been shown to assist birth by shortening the second stage of labour. It is thought that pelvic floor exercises during pregnancy help to increase flexibility, endurance and muscle control, enhancing the movement (descent and rotation) of the fetal head through the birth canal.

Secondly, antenatal pelvic floor muscle exercises have been listed by the Australian Commission on Safety and Quality in Healthcare, alongside perineal massage, as actions recommended to be performed by pregnant women to reduce the risk of severe perineal lacerations (third- and fourthdegree perineal tears).

Antenatal perineal massage is a technique performed by women, usually in the last four to six weeks of pregnancy, that has also been shown to reduce the incidence of episiotomy, shorten the second MEDICAL FORUM | WOMEN 'S HEALTH

stage of labour, and improve Apgar scores at one and five minutes.

Perineal massage during pregnancy helps to prepare the perineum and surrounding structures of the vaginal opening for the stretch applied during birth by increasing flexibility and circulation.

Thirdly, from the current evidence, we are confident that pelvic floor muscle training during pregnancy can reduce the risk of urinary incontinence. Continent women who perform pelvic floor muscle training during their pregnancy are 62% less likely to report urinary incontinence in late pregnancy and three months postpartum.

used by women as they are scared to do more harm than good. It is therefore vital that as their care providers we discuss the benefits and provide clear direction on how to complete them.

Current best practice guidelines for pelvic floor muscle training recommend individualised assessment and supervision through regular sessions with a pelvic health physiotherapist.

– References available on request Author competing interests - nil

Pelvic floor exercises and perineal massage are low-risk and low-cost interventions that are often not MAY 2022 | 63

Pelvic Congestion Syndrome – too much blood, too little awareness!

By Dr Anjana Thottungal, Obs & Gynae Sonologist, Mt Lawley Pelvic venous system comprises of a rich network of anastomosed collecting vessels encompassing mainly the uterine, ovarian and internal iliac veins.

Pelvic congestion syndrome (PCS) is a condition involving dilated/ varicose veins in the pelvis, typically causing chronic noncyclical abdominal pain for over six months duration in the absence of known pelvic pathology, with a considerable negative effect on quality of life. Though over 30% pelvic pain is caused by PCS, diagnosis is often delayed.

Pain from PCS is usually worsened during menstruation, intercourse, bladder or bowel movements and gestation. Clinical manifestations such as menorrhagia, dysmenorrhea, dyspareunia, post

PCS is often misdiagnosed as endometriosis due to similarities in presenting symptoms.

The aetiology of PCS is thought to be pelvic venous hypertension due to incompetent valves. There is a positive association between oestrogen levels and varicose veins suggesting that higher levels of this hormone increase venous dilation.

The pathophysiological mechanism of pain in PCS is believed to be engorgement of pelvic veins, resulting in the compression of adjacent pelvic organs. Studies have demonstrated that increased serum oestrogen is directly proportional to higher levels of patient pain.

Dialated pelvis adnexal veins in a 19yo nulliparous patient.

coital ache, severe ovulation pain, rectal pain, bladder irritability, left lateral vaginal tenderness, pelvic pressure/discomfort on prolonged sitting or standing, pain in the back or hip can result from PCS.

Transvaginal scan (TVS) is the most commonly used imaging modality to identify pelvic pathology, being minimally invasive, non-

This can significantly impact the daily lives of those living with it.

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CLINICAL UPDATE

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CLINICAL UPDATE ionising, cost-effective and readily available. As pelvic pain is one of the most common reasons for pelvic ultrasound referral, TVS is an effective diagnostic tool for PCS, and the role of TVS is increasing in the identification of this condition.

Dilation of pelvic veins is measured based on diameter, with the generalised normal range being between 2-4mm. A reference range has been established for uterine vein diameter of both nulliparous and parous women. For premenopausal nulliparous women, veins measuring 6mm and above can undoubtedly be considered as dilated.

The treatment of PCS can be conservative. However, modern minimally invasive endovascular treatments are highly effective and shown to result in alleviation of symptoms, greatly improving their quality of life in a low-risk day case setting.

When pelvic varicosities are not assessed in routine pelvic ultrasounds, the identification of PCS is prolonged, leading to unnecessary patient suffering.

Among the diverse aetiologies,

PCS is a common cause in approximately one third of patients with chronic pelvic pain.

Due to the extensive range of gynaecological causes of pain and lack of knowledge in many of these areas, delay in diagnosis can also result in investigation in the wrong direction. These factors reinforce the importance of assessing and measuring veins in the pelvis in routine transvaginal scans.

Research into PCS in nulliparous females is limited to small number of case reports. However, recent studies increasingly report existence of this condition in young, nulliparous women, despite its association with pregnancy and increased age. The incidence of PCS increases with age in premenopausal women, peaking at 4150 years old. Further investigation into this phenomenon would be beneficial in increasing clinicians’ understanding of PCS and its occurrence in younger populations, improving their ability to diagnose and effectively treat the condition.

Pelvic congestion syndrome should not be dismissed as a differential diagnosis in those presenting with

chronic pelvic pain, especially on the basis of parity.

Preliminary data from our unit showed that about 40% of patients with PCS on pelvic scan were nulliparous and under 35 years of age with the majority being referred for suspected endometriosis.

About 50% of young nulliparous patients who were referred for pain symptoms were found to have PCS on pelvic scan.

A pelvic scan is an essential investigation that can initially suspect pelvic congestion as well as reliably rule out all gynaecological causes for chronic pelvic pain such as endometriosis, pelvic inflammatory disease, adenomyosis and fibroids etc.

Such a scan report would direct the treatment journey of these women in the right direction as PCS is one of the most underdiagnosed, misdiagnosed, ignored, and undertreated gynaecological if not medical conditions in women.

References available on request Author competing interests – nil

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MAY 2022 | 65

Music soothes a GP’s soul

A life-long music lover, Dr Jenny Fay believes in its power to help and heal as well as the benefits of singing in a group.

By Ara Jansen Dr Jenny Fay is a born generalist, which is why she’s a GP. It also means when it comes to her other passion – music – she’s not content to be part of just one group.

A singer, pianist, flute and piccolo player and occasional ukulele strummer, Jenny is a member of the WA Symphony Orchestra Chorus, an orchestra, an a capella group and she also helps assess and arrange music. She also loves to harmonise.

“I love being a GP, I really do,” Jenny says. “I couldn’t have done a specialty; it would have bored me.

“I was always going to be a music teacher as all my family were teachers. At the last minute I thought I would put medicine down. It was a good decision. I’ve always said I love medicine and music is a wonderful hobby. That’s a good order for me to have things in. I love to have both things going and I work to support my hobbies.”

Those hobbies include organiser and performer in WA Doctor’s Orchestra, which plays for charity every two years and has been going since 2006. It includes medical doctors, medical students, those in allied health and even the odd veterinarian.

Players range in age from their 20s up to 70 plus. Each performance includes a soloist from their medical ranks such as dermatologist Dr Roland Brand on piano and this year medical student Emily Leung will perform Tchaikovsky’s Violin Concerto. She jokingly calls them a bit of a “rusty orchestra” but they’ll be practising ahead of a concert later this year.

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LIFESTYLE

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LIFESTYLE

Dr Jenny Fay, far right, and the doctors in the WASO Chorus with chorus director Andrew Foote.

She’s also part of Naya Chorale, a 30-strong group that performs a capella and reimagined versions of contemporary and popular songs.

Her 27-year-old son is also part of the group and she’s one of the older members.

Jenny says singing, which is what she mostly does over playing an instrument, is great for stress.

She reckons she can go a bit mad without a regular dose.

Luckily, between rehearsals and performances, she’s never far away for a chance to sing out. While it has been difficult of late to sing in masks at rehearsals, it is surprisingly manageable.

“When you play or sing, you use a whole different part of your brain – and there’s science to back that up.

You switch off your working brain and that’s one of the big benefits.

“While I don’t sing my way around the office, I sing a lot at home, and I bellow away in the car. If I’m on the way to WASO rehearsals I’ll warm up in the car, which must be strange for the people in cars next to me.”

Jenny has been part of the WASO Chorus for 16 years and isn’t the only medico in the ranks. She’s joined by several GPs, a psychiatrist, two anesthetists, a pediatrician and an ED specialist.

On May 15 the chorus performs Cherubini’s Requiem in St Mary’s Cathedral. Jenny is excited because MEDICAL FORUM | WOMEN 'S HEALTH

she’s never performed the piece before.

“With the WASO, the big and popular pieces come around often.

This one will be chorus and organ.

It’s an absolutely beautiful piece and when I first sang it, I wondered why it wasn’t better known. It’s such a stirring piece, dramatic and with lovely harmonies.”

also something Jenny loves to experience, whether it’s the whole room as a piece hits a high moment or that whoosh of an intake of breath or an exhale as something resolves.

“There’s a frisson or a sigh at the end of a piece and you know you’ve reached someone – or everyone. I hope for a transporting freedom for everyone when they listen to music.”

For Jenny, music is about release and escape from day-to-day stress and interaction with people. As a GP, seeing new patients every 15 minutes or so can make you sick of talking.

Singing in a group also allows someone else to take charge and allows her to connect emotionally with what she’s singing.

If you think this doctor has enough on her plate, she’s also part of a book club which has been going for three decades. Ten friends from their community theatre days gather once a month with a book, drinks and a bit of gossip. This time Jenny is one of the youngest in the group which ranges upwards to 70.

“I love the idea that you get these people from all over the community into a space. Together they make something out of nothing and then they scatter to the winds again after you’re done. That really impresses and excites me. You each bring your best and the sum is always greater than the parts as your voice becomes part of the bigger sound.

“I don’t sit still very well. Taking time off to do nothing is quite hard. But I also have to be careful talking all day and resting my voice enough to sing.

Music gives me the brain rest from work and is truly a joy.”

“I love just being in that moment.

Sometimes it’s emotional and there are times in your life when it’s hard to focus or the music is moving and sad. It can also be really happy and if you are struggling, it can be consoling.”

WASO Chorus sings Cherubini’s Requiem on Sunday, May 15 at St Mary’s Cathedral. Tickets from: https://www.waso.com.au/ concerts-tickets/whats-on/ concert/cherubini

The visceral reactions of the audience to a performance are MAY 2022 | 67

Magic happens all at Once

More than just a musical about two characters who are an antidote for each other, the stage production of Once reminds us of the power of vulnerability.

By Ara Jansen

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unique to this cast and would balance with the incredible collection of songs.

“I think we’ve created something that is a very theatrical experience for the audience,” he says. “It’s about learning to be vulnerable and facing our pain and moving through it. I really believe we can change our emotions through music.”

Like the isolation so much of the world is feeling, Carroll says the characters are experiencing a similar thing. There’s a sense of difficulty and the characters just want to keep moving through it but they have to figure out how.

“I think the dynamic of Guy and Girl is relatable, the way they are drawn to each other and wanting to express something but not quite having the power to express it. They find that in each other.”

They’re known simply as Guy and Girl. Two lost souls who meet on a Dublin street. Discovering they are both musicians, their story charts a relationship which helps them both heal.

Guy is a guitar-playing Irish singersongwriter while Girl is Czech and a pianist. They meet and connect musically and remind each other how to dream again while sharing a culture foreign to the other.

If you saw the 2007 hit movie Once, starring Glen Hansard, you’ll recognise this story. Now turned into a stage show of the same name, it’s being staged with Black Swan Theatre Company at the Regal Theatre.

The musical – which features the award-winning song Falling Slowly – is also slightly different from a traditional musical in that the actors all sing, dance and play instruments on stage, being their own band.

There are 11 performers in the cast and often just about as many instruments on stage.

One of Carroll’s challenges in staging was to make sure the right instruments were in the right places at the right times.

Director Richard Carroll says the story is as simple as Guy meets Girl and the connection helps them both out of an emotionally stuck time.

“And yet there is so much more – in the detail,” Carroll says in his production notes. “The deceptively spare dialogue, the tiny truths that provoke an unexpected laugh or quietly shatter our hearts.

The catalyst for the lead characters’ bond is, of course, music.

“The songs are beautiful, painful, evocative, funny, truthful, original and unforgettable – and never merely functional. The music and lyrics of Glen Hansard and Markéta Irglová are the beating heart of this show.”

While he’s a fan of the movie and the Broadway cast recording, Carroll hadn’t previously seen the production live and decided to work directly from the script to create a production

Carroll says one of the topical messages in the show is understanding there’s no shame in being vulnerable. Coming from an Irish family and not necessarily being comfortable in expressing emotions he says reminded him that it’s not unique to his family and that people do sometimes feel shame when they want to open up.

“With big subjects and bold ideas, it’s one of the beautiful things about storytelling. You can tell those stories, and something resonates so people just don’t feel alone.

I think it’s a wonderful thing if theatre can get people one step closer to helping them express their emotions.”

Once is at the Regal Theatre from May 28 – June 12.

Tickets from Black Swan Theatre Company.

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MAY 2022 | 69

This is how you please a woman A woman unexpectedly starts a new business which opens a Pandora’s box of pleasure in the locally filmed movie, How to Please a Woman.

By Ara Jansen A love letter to women and female friendships is how actor Caroline Brazier describes her latest movie, which was shot in Fremantle.

How to Please a Woman is a funny and heart-warming liberation story for women who have been afraid to ask for what they want – at home, at work and in the bedroom. It’s also a revealing journey into the vulnerable world of what women really want and how hard it can be to get it right.

“Obviously, the cleaning must be effective and there must be a minimum of one orgasm,” says Gina (played by Sally Phillips) in the film’s trailer when talking to the wellbuilt moving guys who become housecleaners in her new business, Pleased to Move You. In the hands of director Renee Webster in her debut feature film, How to Please a Woman is a lovely balance of humour and tenderness that reflects what women of a certain age – or possibly any age – experience when good sex, caring sex or even respectful sex is absent from their lives.

Alongside Phillips in the lead role and Brazier as a close friend, it also stars well-known faces in Erik Thomson, Cameron Daddo, Alexander England, Hayley McElhinney and Tasma Walton.

70 | MAY 2022

The film has had a limited release at various summer film festivals but hits cinemas in May and Brazier says it has already struck a chord with people because of its sensitive and honest exploration of pleasure in a group of 50-something women.

Known for roles in shows such as Packed to the Rafters, Rake and Tidelands, Brazier plays Sandra, one of the close friends who supports Gina in her new venture. The four women meet regularly to swim at Leighton Beach and numerous scenes are filmed inside the changerooms where the characters gossip and women hear about Gina’s unexpected business.

“We haven’t given up on sex and we’re sick of cleaning the house,” says one. “There are a lot of women who like the idea of a man cleaning their house,” says another as Gina’s ocean-swimming community respond immediately to her business.

“There’s a notion of how much pleasure you are allowed to have at a certain age and how mean we are to ourselves about it,” says Brazier.

“While it’s a film about sex, it feels more about life and sex is the scaffolding which offers the characters a place to find their voice, learn how to breathe, speak and take-up space and feel how they are entitled to.

“It’s also about sexual pleasure but it is never feels sleazy. I feel like there’s so much stuff underlying the movie, so many themes and ideas worthy of discussion.”

Brought back to her hometown of Perth because of the pandemic, Brazier has kept busy professionally with this film and a number of other projects and most recently being seen in Perth Festival’s Mary Stuart with American transplant Kate Walsh (Emily in Paris and The Umbrella Academy).

With shooting happening in Fremantle and at Leighton, Brazier says it was a joy to be able to do a film where the set was only a long song drive from home. Being close to the beach and having a large number of women as part of the cast and crew also made for a wonderful experience.

How to Please a Woman is in cinemas from May 19.

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