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Survivorship treatment summaries and care plans are increasingly incorporated into cancer care but there are limited data on their accuracy and acceptability. We have evaluated written care plans developed as part of a once‐off, nurse‐led survivorship consultations across four medical oncology clinics in South Australia as part of a state‐wide pilot. While the accuracy of treatment summaries was high, level of detail in care plans was moderate to low, as was survivors' perception of plans' utility. Refereed/Peer-reviewed

Background: Sarcomas comprise a heterogenous group of malignant tumours of mesenchymal origin and can arise in the skin. Definitive management of skin sarcoma usually entails surgical resection with wide margins, often requiring reconstruction. The incidence and demographics of these neoplasms in Australia are poorly understood. Method: Incidence, gender and age distribution data for skin sarcomas for the period 1982–2009 were obtained from the Australian Cancer Database (ACD). Morphology and topographical region coding via the International Classification of Diseases for Oncology third edition (ICD-O-3)1 were used to identify the data.Results: A total of 5453 cases of skin sarcoma in the Australian population were identified over the 28-year period. Anatomically, 1610 cases (29%) occurred on the limbs, 1416 (26%) on the head and neck area, 957 (18%) on the trunk and 1470 (27%) had an unspecified skin origin. Overall incidence was 2.09 per 100,000 population. Males were more commonly affected (70%), most commonly in the 30–49 years and 70+ years age groups. The most common pathological subtypes were fibromatous sarcoma (including dermatofibrosarcoma protuberans), Kaposi’s sarcoma and pleomorphic dermal sarcoma.Conclusion: The Australian Cancer Database data used to describe the pattern and epidemiological trends for skin sarcoma in Australia demonstrated variation from international trends and highlight the need for further research into the aetiology of these tumours.

Refereed/Peer-reviewed Objective: This study aimed to compile and synthesize evidence regarding the effectiveness of quality improvement interventions in radiology and the experiences and perspectives of staff and patients. Methods: Databases searched for both published and unpublished studies were as follows: EMBASE, MEDLINE, CINAHL, Joanna Briggs Institute, Cochrane Central Register of Controlled Trials, PsycINFO, Scopus, Web of Science, Mednar, Trove, Google Gray, OCLC WorldCat, and Dissertations and Theses. This review included both qualitative and quantitative studies of patients undergoing radiological examinations and/or medical imaging health care professionals; a broad range of quality improvement interventions including introduction of health information technology, effects of training and education, improved reporting, safety programs, and medical devices; the experiences and perspectives of staff and patients; context of radiological setting; a broad range of outcomes including patient safety; and a result-based convergent synthesis design. Results: Eighteen studies were selected from 4846 identified by a systematic literature search. Five groups of interventions were identified: health information technology (n = 6), training and education (n = 6), immediate and critical reporting (n = 3), safety programs (n = 2), and the introduction of mobile radiography (n = 1), with demonstrated improvements in outcomes, such as improved operational and workflow efficiency, report turnaround time, and teamwork and communication. Conclusions: The findings were constrained by the limited range of interventions and outcome measures. Further research should be conducted with study designs that might produce findings that are more generalizable, examine the other dimensions of quality, and address the issues of cost and risk versus benefit.

Background Surveillance imaging is used to detect local and/or distant recurrence following primary treatment of localised soft tissue sarcoma (STS), however evidence supporting optimal surveillance modality or frequency is lacking. We used prospectively collected sarcoma data to describe current surveillance imaging practice in patients with AJCC stage II and III extremity STS and evaluate its cost-effectiveness. Methods From three selected Australian sarcoma referral centres, we identified patients with stage II and III extremity STS treated between 2009 and 2013. Medical records were reviewed to ascertain surveillance imaging practices, including modality, frequency and patient outcomes. A discrete event simulation model was developed and calibrated using clinical data to estimate health service costs and quality adjusted life years (QALYs) associated with alternative surveillance strategies. Results Of 133 patients treated for stage II and III extremity STS, the majority were followed up with CT chest (86%), most commonly at 3-monthly intervals and 62% of patients had the primary site imaged with MRI at 6-monthly. There was limited use of chest-X-ray. A discrete event simulation model demonstrated that CT chest screening was the most cost effective surveillance strategy, gaining additional QALYs at a mean incremental cost of $30,743. MRI alone and PET-CT alone were not cost-effective, whilst a combined strategy of CT + MRI had an incremental cost per QALY gained of $96,556. Conclusions Wide variations were observed in surveillance imaging practices in this high-risk STS cohort. Modelling demonstrated the value of CT chest for distant recurrence surveillance over other forms of imaging in terms of cost and QALYs. Further work is required to evaluate cost-effectiveness in a prospective manner.

Aim:To review, test and refine standardised tools for nurses to initiate treatment summaries and care plans, and identify barriers and enablers to providing them. Background:This paper reports on a pilot study informed by the development of a Survivorship Framework in South Australia. Methods:Expression of interest was sought for adult medical oncology services to pilot standardised tools within existing services and resources. A quality improvement approach was used over three months with nurse practitioners and nurse practitioner candidates to obtain feedback, refine tools and resources, and identify barriers and enablers. Quantitative and qualitative data was recorded at each site using spreadsheets, at fortnightly meetings, and at a final debriefing. Content analysis was used to identify key themes in the context of barriers and enablers. Findings:Four medical oncology clinics in South Australia participated (three metropolitan, one regional). Forty-three consultations were delivered at three sites. Barriers included time to complete documentation, perceived knowledge and skills, re-orientation of clinics and referral pathways, competing service priorities and lack of administrative support. Enablers included interrelationships within and between pilot teams, supporting resources, and increased familiarity with tools. Discussion and conclusion:There is potential for nurses to initiate treatment summaries and care plans in the treatment setting with the use of standardised tools. Further refinements are needed to make the process less time burdensome, additional specialised training is needed to improve confidence of nurses to work in a wellness model, and numerous system challenges need to be overcome to improve overall feasibility of using standardised tools to provide survivorship support to patients. Lack of systems to populate information, and lack of referral processes to support survivorship discussions with patients are likely to limit the initiation of survivorship care in treatment settings in South Australia. Further nurse-led development of tools for treatment summaries and care plans should occur in parallel with translational research designed to address system challenges. What is already known about this topic?– Structured survivorship care is recommended to facilitate the individual follow-up needs, health and wellness of people treated for cancer. Many health services are grappling with the challenge of delivering survivorship care in a sustainable way. It is clear that embedding survivorship care routinely and at scale presents a significant implementation challenge for oncology services. What this paper adds.– Nurses are well placed to lead the initiation of treatment summaries and care plans, however, this pilot provides real-world insight into the system and practical challenges that need to be addressed to provide essential components of survivorship care in South Australia https://doi.org/10.37464/2020.371.3

Background Sarcomas affecting the head and neck often require complex management due to the combination of anatomic, aesthetic and oncological considerations. The incidence and patterns of presentation are poorly understood and have not been reviewed in the Australian population. Method This study sourced incidence and demographic data from the National Cancer Registry at the Australian Institute of Health and Welfare for the years 1982-2009 (corresponding to 97.3% of the Australian population). All cases of sarcoma, according to ICD-O-3 classification ((International Classification of Diseases for Oncology, 3rd edition), were assessed. Results A total of 3911 new cases of sarcoma affecting the head and neck were recorded during the period 1982-2009, including 1383, 2106 and 442 cases arising from skin, soft tissue and bone, respectively. The annual incidence rate of sarcomas affecting the head and neck was 1.59 per 100 000 population. The incidence of head and neck sarcoma rose substantially in older age groups (age 65 years and above) and was most common in male patients (69%). Malignant fibrous histiocytoma (MFH) was the most common pathology. There was an increase in incidence in skin-origin sarcoma in the head and neck, particularly affecting elderly males. Conclusion The incidence of head and neck sarcoma in Australia is higher than that reported for an equivalent European population. The increase in MFH arising from the skin in elderly male patients mirrors the patterns of common cutaneous malignancy, particularly melanoma, suggesting that ultraviolet radiation is an epidemiological factor. Management of head and neck sarcoma is complex and best managed in a specialist multidisciplinary environment.

Background: Soft tissue sarcomas (STS) are rare, often fatal tumors, but little is known of the epidemiology and survival in the Australian population. This study aims to provide the first epidemiological analysis of incidence and survival rates of STS in the Australian population. Methods: A retrospective population-based observational study was conducted between 1982 and 2009 of all patients with a diagnosis of STS using the Australian Institute of Health and Welfare (AIHW) Australian Cancer Database. Incidence rates per 100,000; incidence rate ratios, age-standardized incidence rates, prevalence and incidence rates of subtypes of STS, median, one-year and 5-year survival rates were examined. Results: A total of 26,970 patients were identified. Between 1982 and 2009 STS incidence rates significantly increased from 3.99 [95% CI 3.68–4.32] to 6.12 [95% CI 5.80–6.46] per 100,000 Australian population, with a peak incident rate ratio (IRR) of 1.59 [95% CI 1.51–1.69] (p < 0.0001) in 2001. Median age at diagnosis increased from 58 to 63 years. Incidence rates were stable across all 10-year age cohorts, except for people aged over 70 where it increased. Overall, age-standardized incidence rates increased from 4.70 [95% CI 4.42–5.00] in1982 to 5.87 [95% CI 5.63–6.11] per 100 000 Australians in 2009. Leiomyosarcoma (20.43%), malignant fibrous histiocytoma (16.14%), and soft tissue tumors/sarcomas, not otherwise specified (10.18%) were the most common STS subtypes. Median survival from diagnosis increased from 5.80 years [95% CI 5.06–6.54] in 1985–1989 cohort to 8.18 years [95% CI 7.54–8.81] in the 2000–2004 cohort (log-rank test p < 0.0001). Conclusion: The incidence of STS is increasing in Australia, most noticeably in those aged over 70 years, with a small but statistically significant increase in overall survival rates. Refereed/Peer-reviewed

Objective Currently all women who have completed their primary treatment for early breast cancer are invited to receive routine annual mammography. There is no randomized controlled trial evidence to support this schedule, and model-based analysis is required. This paper describes a novel data collection and model calibration process to analyze the cost-effectiveness of alternative follow-up schedules for early breast cancer survivors. Methods A discrete event simulation model describes the progression of early breast cancer after the completion of primary treatment, representing impalpable and palpable recurrence and the detection of impalpable disease via follow-up mammography. Retrospective data from the South Australian Cancer Registry and clinical and administrative hospital databases were linked for 407 postmenopausal women diagnosed with moderate-prognosis early breast cancer from 2000 to 2008. These data formed the basis of a patient-level probabilistic calibration process. Results For 50- to 69-year-old survivors, annual follow-up for 5 years, with visits every 2 years thereafter, appears to be cost-effective. For women aged 70 to 79 years at diagnosis, a surveillance schedule similar to general population screening (2 yearly) appears to be most cost-effective if high rates of adherence can be maintained. Conclusions This study demonstrated the potential value of combining linked, retrospective data and decision analytic modeling to provide estimates of costs and health outcomes that are sufficiently robust to inform cancer clinical guidelines and individual patient decisions regarding appropriate follow-up schedules.

Summary Background Clinical practice guidelines should aim to assist clinicians in making evidence-based choices in the care of their patients. This review attempts to determine the extent of evidence-based support for clinical practice guideline recommendations concerning cutaneous melanoma follow up and to evaluate the methodological quality of these guidelines. Methods Current guidelines providing graded recommendations regarding patient follow up were identified through a systematic literature review. The authors reviewed the evidence base used to formulate recommendations in each of the guidelines and appraised the quality of the guidelines using the AGREE II (Appraisal of Guidelines for Research and Evaluation) instrument. Results Most guideline recommendations concerning the frequency of routine skin examinations by a clinician and the use of imaging and diagnostic tests in the follow up of melanoma patients were based on low-level evidence or consensus expert opinion. Melanoma follow-up guidelines are of variable methodological quality, with some guidelines not recommended by the appraisers for use in clinical practice. Conclusion Clinicians should be aware of how scant the evidence base is for many recommended courses of action. As a consequence of the paucity of evidence in the field of melanoma follow up, there is considerable variability in the guidance provided. The variable methodological quality of guidelines for melanoma follow up could be improved by attention to the criteria described in AGREE II.

Background:Early diagnosis and improved treatment outcomes have increased breast cancer survival rates that, in turn, have led to increased numbers of women undergoing follow-up after completion of primary treatment. The current workload growth is unsustainable for breast cancer specialists who also provide care for women newly diagnosed or with a recurrence. Appropriate and acceptable follow-up care is important; yet, currently we know little about patient preferences. The aim of this study was to explore the preferences of Australian breast cancer survivors for alternative modes of delivery of follow-up services.Methods:A self-administered questionnaire (online or paper) was developed. The questionnaire contained a discrete choice experiment (DCE) designed to explore patient preferences with respect to provider, location, frequency and method of delivery of routine follow-up care in years 3, 4 and 5 after diagnosis, as well as the perceived value of 'drop-in' clinics providing additional support. Participants were recruited throughout Australia over a 6-month period from May to October 2012. Preference scores and choice probabilities were used to rank the top 10 most preferred follow-up scenarios for respondents.Results:A total of 836 women participated in the study, of whom 722 (86.4%) completed the DCE. In the absence of specialist follow-up, the 10 most valued surveillance scenarios all included a Breast Physician as the provider of follow-up care. The most preferred scenario is a face-to-face local breast cancer follow-up clinic held every 6 months and led by a Breast Physician, where additional clinics focused on the side effects of treatment are also provided.Conclusion:Beyond the first 2 years from diagnosis, in the absence of a specialist led follow-up, women prefer to have their routine breast cancer follow-up by a Breast Physician (or a Breast Cancer Nurse) in a dedicated local breast cancer clinic, rather than with their local General Practitioner. Drop-in clinics for the management of treatment related side effects and to provide advice to both develop and maintain good health are also highly valued by breast cancer survivors. Refereed/Peer-reviewed

Investigating patients’ reports on the quality and consistency of melanoma follow-up care in Australia would assist in evaluating if this care is effective and meeting patients’ needs. The objective of this study was to obtain and explore the patients’ account of the technical and interpersonal aspects of melanoma follow-up care received. An online survey was conducted to acquire details of patients’ experience. Participants were patients treated in Australia for primary melanoma. Qualitative and quantitative data about patient perceptions of the nature and quality of their follow-up care were collected, including provision of melanoma specific information, psychosocial support, and imaging tests received. Inconsistencies were reported in the provision and quality of care received. Patient satisfaction was generally low and provision of reassurance from health professionals was construed as an essential element of quality of care. “Gaps” in follow-up care for melanoma patients were identified, particularly provision of adequate psychosocial support and patient education. Focus on strategies for greater consistency in the provision of support, information, and investigations received, may generate a cost dividend which could be reinvested in preventive and supportive care and benefit patient well-being.

Objectives: International guidelines recommend annual mammography after early breast cancer, but there is no randomized controlled trial evidence to support this schedule over any other. Given that not all women have the same risk of recurrence, it is possible that, by defining different risk profiles, we could tailor mammographic schedules that are more effective and efficient.Methods: A discrete event simulation model was developed to describe the progression of early breast cancer after completion of primary treatment. Retrospective data for 1,100 postmenopausal women diagnosed with early breast cancer in South Australia from 2000 to 2008 were used to calibrate the model. Women were divided into four prognostic subgroups based on the Nottingham Prognostic Index of their primary tumor. For each subgroup, we compared the cost-effectiveness of three different mammographic schedules for two different age groups.Results: Annual mammographic follow-up was not cost-effective for most postmenopausal women. Two yearly mammography was cost-effective for all women with excellent prognosis tumors; and for women with good prognosis tumors if high compliance rates can be achieved. Annual mammography for 5 years and 2 yearly surveillance thereafter (a mixed schedule) may be cost-effective for 50- to 69-year-old women with moderate prognosis tumors, and for women aged 70–79 years with poor prognosis tumors. For younger women with poor prognosis tumors, annual mammography is potentially cost-effective.Conclusions: Our results suggest that mammographic follow-up could be tailored according to risk of recurrence. If validated with larger datasets, this could potentially set the stage for personalized mammographic follow-up after breast cancer.

Comparative effectiveness research is intended to provide evidence to improve patient outcomes through the use of the most appropriate health technology affordable. The authors present 5 case studies, focusing on the use of plain radiography in common clinical scenarios, to illustrate the considerable scope for comparative effectiveness research within medical imaging and the different levels of evidence currently in existence to guide the improved use of medical imaging. These are blunt ankle injury, breast cancer follow-up, low back pain, routine daily chest x-rays in intensive care, and screening for breast cancer. Although there are established models for evaluating new technologies, especially pharmaceuticals, against the most commonly used current technology, the evaluation of technologies in current clinical practice is in an early phase of development. Because evaluation resources are limited, one major challenge is developing ways to identify established technologies for evaluation to refine the indications for their use. A set of criteria with which to identify established technologies that may not be delivering value for money is described, and their use is illustrated in relation to the 5 case studies. These criteria could be incorporated into literature search strategies, stakeholder consultations, and utilization scanning. Once identified, these technologies should be formally evaluated for their performance in improving patient health without restricting the availability of other effective interventions.

Research is needed into current melanoma follow-up practices and their implications for patients and society. We highlight the need and suggest a way forward.

Problem Despite widespread acceptance of the Ottawa ankle rules for assessment of acute ankle injuries, their application varies considerably. Design Before and after study. Background and setting Emergency departments of a tertiary teaching hospital and a community hospital in Australia. Key measures for improvement Documentation of the Ottawa ankle rules, proportion of patients referred for radiography, proportion of radiographs showing a fracture. Strategies for change Education, a problem specific radiography request form, reminders, audit and feedback, and using radiographers as “gatekeepers.” Effects of change Documentation of the Ottawa ankle rules improved from 57.5% to 94.7% at the tertiary hospital, and 51.6% to 80.8% at the community hospital (P