Category: Letters

I am writing in response to the review article by McMullen (AMSJ Volume 1, Issue 1). [1]

The major cause of gynaecologic-related cancer mortality in women in developed settings is ovarian cancer. [2] Recent research findings in this field provide hope in relation to both screening and early treatment – even though randomised controlled trial evidence in most screening techniques is still not available.

Serum CA125, which is the most commonly used tumour marker for ovarian cancer, is not suitable for population-based screening as it has been found to be elevated in only five to six out of ten women with stage I epithelial ovarian cancer. [3] Screening and diagnosis may therefore have to incorporate a variety of other tools. Primary prevention also needs to be considered.

Primary prevention is aimed at risk factors for ovarian cancer. A study of Australian women found an increased ovarian cancer risk related to high dietary intake of red and processed meat and fat. [4]

A meta-analysis found that smoking may increase the risk of developing mucinous ovarian cancer twofold. [5] Other studies have shown reduced serous ovarian cancer risk with hormonal contraceptive use, breastfeeding duration and increasing parity. [6] Health care workers could contribute to primary prevention by encouraging patients to quit smoking, change dietary habits and breastfeed their babies.

Screening is a type of secondary prevention. Screening will have a higher yield if it is targeted at people at increased risk. Multiple primary cancer links were found in an assessment of South Australian Cancer Registry data which suggested screening for ovarian cancers in patients with colon cancer or cancer of the uterus. [7]

Genetic counselling and testing is a good screening tool in persons at high risk of ovarian cancer and persons with familial ovarian cancer history. [8] Carriers of BRCA1 and BRCA2 mutations account for up to 15% of ovarian tumours. [9] Genetic advances have also identified GTF2A1 and GTF2A1 plus HAAO as principal markers in ovarian cancer diagnosis. [10]

As for the actual screening test to be used, urine angiostatin levels are elevated in patients with epithelial ovarian cancer and have been shown to be a superior marker in detection of epithelial ovarian cancer as compared to CA125. [11] Differentiation of cancer from healthy controls had a sensitivity of 88% and specificity of 92%; while differentiation of benign from neoplastic lesions had a sensitivity of 84% and specificity of 84%. When used in combination with CA125, 91% of ovarian cancers were identified.

Transvaginal ultrasonography has also been shown to be of use in diagnosis, especially in augmentation of CA125 screening. [12] Multimodal screening, on the other hand, involving CA125 and ultrasonography in a pilot randomised trial has a positive predictive value of 21% with prolonged survival rates. [13]

In conclusion, serum CA125 is an inadequate solitary predictor in the diagnosis of ovarian cancer. Upcoming diagnostic methods provide an unprecedented opportunity to combine methods and thus improve diagnosis in Australia.

References

[1] McMullen D. Ovarian carcinoma: Classification and screening challenges. Australian Medical Student Journal 2010;1(1):35-7.

[2] Costi M, Zeillinger R. Drug resistance in ovarian cancer: Biomarkers and treatments. Highlights from the DROC meeting held in Modena (Italy) on the 19th and 20th of February 2009. Scientific topics discussed at the meeting are reported in the present issue. Gynecol Oncol 2010;117(2):149-51.

[3] Moore R, MacLaughlan S, Bast Jr. R. Current state of biomarker development for clinical application in epithelial ovarian cancer. Gynecol Oncol 2010;116(2):240-5.

[4] Kolahdooz F, Ibiebele T, Van Der Pols J, Webb P. Dietary patterns and ovarian cancer risk. Am J Clin Nutr 2009;89(1):297-304.

[5] Jordan S, Whiteman D, Purdie D, Green A, Webb P. Does smoking increase risk of ovarian cancer? A systematic review. Gynecol Oncol 2006;103(3):1122-9.

[6] Jordan S, Green A, Whiteman D, Moore S, Bain C, Gertig D, et al. Serous ovarian, fallopian tube and primary peritoneal cancers: A comparative epidemiological analysis. Int J Cancer 2007;122(7):1598-603.

[7] Heard A, Roder D, Luke C. Multiple primary cancers of separate organ sites: Implications for research and cancer control (Australia). Cancer Causes and Control 2005;16(5):475-81.

[8] Petrucelli N, Daly M, Feldman G. Hereditary breast and ovarian cancer due to mutations in BRCA1 and BRCA2. Genet Med 2010;12(5):245-59.

[9] Despierre E, Lambrechts D, Neven P, Amant F, Lambrechts S, Vergote I. The molecular genetic basis of ovarian cancer and its roadmap towards a better treatment. Gynecol Oncol 2010;117(2):358-65.

[10] Huang Y, Jansen R, Fabbri E, Potter D, Liyanarachchi S, Chan M, et al. Identification of candidate epigenetic biomarkers for ovarian cancer detection. Oncol Rep 2009;22(4):853-61.

[11] Drenberg C, Saunders B, Wilbanks G, Chen R, Nicosia R, Kruk P, et al. Urinary angiostatin levels are elevated in patients with epithelial ovarian cancer. Gynecol Oncol 2010;117(1):117-24.

[12] Hennessy B, Coleman R, Markman M. Ovarian Cancer. Lancet 2009;374(9698):1371-82.

[13] Jacobs I, Skates S, MacDonald N, Menon U, Rosenthal A, Davies A, et al. Screening for ovarian cancer: A pilot randomised controlled trial. Lancet 1999;353(9160):1207- 10.

It appears that all the students who graduated at the end of 2010 and are now doing their intern year did find a place. But that is unlikely to be the case for all students finishing this year, and in the immediate future.

All medical students who qualify in Australia must be guaranteed access to an intern place, irrespective of how their study was funded or, indeed, which country they are from. This is a critical element to ensuring the ultimate goal for our medical workforce: that it be selfsustaining by 2025. [1]

Medical Deans, which represents all eighteen medical schools in Australia and the two New Zealand medical schools, has been actively seeking a commitment from governments over the past two to three years that there be sufficient and quality intern places available for all medical school graduates.

Unfortunately, while the significant increase in medical student places since 2005 has been well-publicised, it would seem State and Federal governments have only recently undertaken forward planning to accommodate the impact of these increased numbers as students graduate into the intern year, or indeed, move into later post-graduate training.

The increase in the graduating group began to be felt in 2009, but the real pressures on the health system will be in the next two to three years with 3,786 graduates projected for 2014, 1,400 more than in 2009. About 17% of these graduates are likely to be international fee paying students.

A year ago, Federal and State government Health Ministers met and guaranteed places only for Commonwealth-funded students, leaving about one-quarter of our medical students without certainty. By far the significant majority of these are international fee paying students.

International students must continue to be seen as an integral component of Australian medical schools. They are part of the longer term goal of self-sustainability. The impact of not guaranteeing an internship on both the individual student as well as the Australian higher education sector has already been summarised in the first edition of this journal. [2] For Medical Deans, while that impact will be significant on each medical school, it will be felt far beyond: a significant downturn in the number of international students will compromise the wonderful diversity these students bring to our broader community, the value-add they can make to the Australian health care system by already knowing how the system works, and the ability of these students to take their place in the increasing global workforce.

Medical Deans acknowledges that it needs to work in partnership with government and the newly established Health Workforce Australia (HWA) to ensure that there is an agreed national training plan in place as soon as possible to underpin the self-sustainability goal for 2025. Without reliable data, no systematic planning can be undertaken. As Deans we recognise that a national plan will assist us to establish our enrolment targets, particularly with respect to international students, with a level of certainty able to be provided to each student surrounding their internship. We are encouraged that HWA will soon commence the development of that training plan and look forward to working with them.

This current bottleneck at the intern year will of course replicate itself through to vocational training over the next five to ten years. It is critically important therefore that every point across the medical education continuum is addressed through the training plan and sufficient resources for training allocated at each point. Setting targets at each point will enable each level of training to be prepared.

The Medical Schools Outcomes Database and Longitudinal Tracking Project (MSOD) will be most useful in informing the national training plan. This very successful project of Medical Deans will provide much-needed data on whether first year medical students act on their intentions with respect to type and location of future practice, and whether particular initiatives or programs undertaken during their studies have influenced the student’s eventual choice. The data will greatly benefit the targeting of government resources and provide much-needed understanding of future areas of likely workforce gaps.

The Australian Government’s national health reform agenda, to be implemented through the National Health and Hospitals Network, provides a timely opportunity for a number of critical issues in medical education to be addressed. These include the recognition of the true cost of teaching and clinical supervision, the need for better planning and co-ordination of medical education across the whole spectrum of training, ensuring quality teaching continues to be delivered and the current high quality of our graduates is not diminished, and the importance of embedding translational educational research.

These are issues that Medical Deans will continue to address with vigour. In our view, they are critical to ensuring a self-sustaining workforce by 2025 and one which we can continue to proudly promote as outstanding.

References

The AMA is very honoured to be part of the inaugural edition of the Australian Medical Students Journal, and to be involved in the work and thinking of the next generation of medical professionals.

Medical education and training is a key part of any health reform agenda. Without a quality future medical workforce, no health reform will be a success. The AMA keeps reminding Governments of this important fact.

The Commonwealth’s recent health reform announcements are an opportunity to improve and to define more clearly the funding arrangements (and therefore responsibility) across the stages of medical education and training. Like all parts of the health system, clinical training in particular has been caught up in blame shifting. The Commonwealth decides on intakes to medical schools, but the States and Territories provide the lion’s share of clinical training in the public system. This means that while the Commonwealth has embarked on a massive increase in medical student numbers since 2004, there is no guarantee that the States and Territories will supply all the pre-vocational and vocational training positions in public hospitals that are needed for the increased graduate numbers.

The Commonwealth’s plan to identify and fund 60 percent of the costs of training in public hospitals may give the Commonwealth more say in making this happen. The Commonwealth has also recently announced a significant investment in training places. This funding provides for more pre-vocational General Practice placements, more GP vocational training places and more specialist training places in private, community and rural settings. This is great news and is in line with the proposals put forward by the AMA.

States and Territories must now play their part and fund more prevocational and specialist training positions in their public hospitals to make sure that we can give all future graduates a training position. We need to make sure there is the right level of investment in the infrastructure and resources to support these places; quality supervision is key to the successful roll out of these places.

The AMA met with the Minister for Health and Ageing in March to discuss clinical training issues – specifically infrastructure and resources for clinical training, including the AMA proposal for the Government’s new body, Health Workforce Australia, to take a strong role in providing for pre-vocational and vocational training. Currently it only provides for undergraduate clinical training.

Health Workforce Australia funding should supplement the efforts of the States and Territories by funding discrete projects that will boost training capacity across the system. This includes funding for dedicated teaching and training time for senior clinicians, the development of innovative training programs for interns, professional development programs to enhance the teaching capacity of junior doctors, and extra prevocational training positions in community settings.

Importantly, the Government has recently agreed to a continued and expanded role for the Medical Training Review Panel (MTRP). The MTRP has a key role to play in monitoring and reporting on the availability of clinical training places, particularly for pre-vocational doctors such as interns, given the significant increases in medical school places in Australia. The AMA has strong representation on the MTRP.

While there is positive movement by the Government with regards to numbers, we need to make sure that the quality of medical education is not compromised. There is a very real threat to this as Governments attempt to do more with less.

While the AMA appreciates the need to find innovative ways of teaching, methods must respect that quality clinical placements and mentoring by senior doctors must remain the cornerstone of medical education.

We need to constantly remind politicians that it is bad policy to reduce the quality of medical education and training or seek to replace the central role of the doctor with lesser-qualified health workers.

The AMA will be running with many messages this election year – just as we have been doing already on the health reform agenda. Boosting quality medical education and training will be one of those messages.

The Rudd Government knows that Australia needs an effective, streamlined and integrated health workforce if it is to meet the challenges our health system faces in coming years – including the ageing of our population and an uneven distribution of health services.

We recognise that increasing numbers of medical students and junior doctors are coming through the system and we need to ensure that students are provided with quality clinical education and training. Since our election two years ago, the Rudd Government has made significant progress to achieve these goals.

Accordingly, we led the major health workforce reforms agreed to by the Council of Australian Governments in November 2008 and formalised in the National Partnership Agreement on Hospital and Health Workforce Reform. This $1.6 billion package, of which the Australian Government will contribute $1.1 billion, is the largest investment in the health workforce ever made in Australia. This landmark investment includes $1 billion for the clinical training of undergraduate students. Importantly, an agreement was also struck with the states and territories agreeing to provide intern places for students with Commonwealth-supported places.

Another key measure in the package is the establishment of Health Workforce Australia (HWA), an independent, truly national body that will work across the health and education sectors to deliver the right number of high quality health graduates. HWA will support workforce reform initiatives: of particular interest to medical students will be its role in funding, planning and coordinating undergraduate clinical training across all health disciplines and in a variety of settings and locations. It will also provide support for an international recruitment program and capital infrastructure, including for simulated learning environments, innovative clinical teaching and training initiatives and rural clinical school programs.

We are facing a time of great change for our health system. I recently joined the Prime Minister to announce a vision for the future that will be the most significant health reform since the introduction of Medicare. Simply put, this will mean a national hospital network, funded nationally and run locally. The second plank in this reform is that we intend to produce a health workforce that complements and supports this vision – and you, as medical students, are a vital part of that endeavour.

On March 15, the Prime Minister and I announced that the Rudd Government will invest another $632 million to train a record number of doctors – to tackle doctor shortages, expand capacity and deliver better health and better hospitals. This investment will deliver an additional 5,500 new or training General Practitioners, 680 medical specialists, and 5,400 pre-vocational general practice program training places over the next ten years. These major investments will meet projected shortfalls, and help reduce pressure on hospitals by improving access and availability of GP and specialist services.

When you have completed your training, we want you to be proud to be joining the Australian health workforce. So we intend to build for you, and all Australians, a health system that is not only able to cope with the challenges ahead, but do so while offering even better quality, even better access, and even greater choice.

Congratulations on the first edition of the Australian Medical Student Journal and best of luck to all readers with their studies.

Congratulations on the inaugural issue of the Australian Medical Student Journal.

As Australian medical students, you are the future medical workforce studying to shape the health and well-being of the next generation of Australians.

This is an exciting time to join the medical profession, in the midst of the biggest reform to the health and hospital system since the introduction of Medicare. Recently, I announced the Government’s National Health Reform Plan. The Plan is based on a vision that future generations will enjoy world class, universally accessible health care — the quality of care that has helped deliver Australians the third longest life expectancy in the world.

The Reform Plan will build on the strengths of our current health system, such as access to primary health care through Medicare, and free public hospital treatment for public patients. We want to improve public hospital and primary health care services, since these services underpin Australia’s entire health system.

Most importantly, the Reform Plan will harness and build on the skills, experience and ingenuity of those, such as yourselves, who work on the front line of our health and hospital system.

Yours is the work of saving lives – restoring, curing and protecting the young; the old; rich and poor alike – through life-changing treatments, discoveries and breakthroughs. It is work that I appreciate. Work that all Australians appreciate.

Australia needs students such as yourselves to achieve the breakthroughs in medical science that prevent disease, cure illnesses and deliver a better quality of life. I wish each of you all the very best for your future endeavours, and I commend you for choosing a profession which is so important to the future of our nation.

We have good reason to be concerned about the mental health of our young people.

In Australia, mental health issues account for 55% of the total burden of disease in those aged between 15-24 years, with depression, anxiety and substance misuse being the most prevalent problems in this age group. [1,2] Furthermore, epidemiological evidence tells us that over 75% of people who suffer from a mental illness experienced their first episode by the age of 25 years. [3] Given the exquisite developmental sensitivity of this period of life, when psychological, social and vocational pathways are being established as part of the transition to independent adulthood, it is not surprising that mental disorders, even relatively brief and mild ones, can disrupt and disable, seriously limiting or even blocking a young person’s potential. Ample evidence shows that mental ill-health in young people is associated with high rates of enduring disability, including school failure, unstable employment, poor social and family functioning, which all too often lead to a spiral of disability and disadvantage that becomes difficult to reverse.

As a society, we cannot afford to ignore the human, social and economic consequences of this situation. A recent report by Access Economics has estimated that in 2009, the financial cost of mental illness in Australians aged between 12 and 25 years was $10.6 billion, with 70.5% of this due to the costs of lost productivity due to lower employment, absenteeism and premature death. Furthermore, the value of the loss in well-being (disability and premature death) was estimated at a further $25 billion. [4] We need to invest in our future, and clearly, investing in youth mental health makes good sense: a strong focus on young people’s mental health has the capacity to generate greater personal, social and economic benefits than intervention at any other time in a person’s lifespan. Put simply, mental health equates with national wealth, in the broadest possible sense.

Fortunately, there is a growing movement that aims not only to raise awareness of this crying area of unmet need, but also to redress it. In the early 1990s we began to promote the idea that intervention in the very early stages of the development of a mental illness was the most effective strategy to reduce the burden of disease created by these disorders. Intervening early to stop the progression of a mental illness should also prevent the accumulation of collateral damage to educational, social and vocational functioning associated with the evolution of the illness. Evidence supporting this proposition has been building steadily over the last decade, and with this progress, it is now accepted at both the State and Federal Government levels, as well as within the wider community, that major reform and significant investment is required in mental health care in Australia, and indeed world-wide.

As Australian doctors, present and future, we live in exciting times. We have reached the tipping point; reform is inevitable, and indeed, the first steps have been taken. A career in psychiatry has always offered benefits such as real contact with patients, rewarding work, intellectual stimulation, interesting research questions and the possibility of maintaining a good work/life balance, but now Australia’s psychiatrists have the potential to be part of a social climate change not only here in Australia, but also world-wide. The need is only too real, and the potential to address it has never been better. As Australia’s doctors of the future, an exciting career option beckons you: consider psychiatry, and make a real difference to our future.

References

[1] Public Health Group. Victorian Burden of Disease Study: mortality and morbidity in 2001. Melbourne: Victorian Government Department of Human Services; 2005.

[2] Australian Bureau of Statistics. National Survey of Mental Health and Well-being. Summary of Results. Canberra: Australian Bureau of Statistics; 2008.

[3] Kessler RC, Berglund P, Demler O, Jin R, Merikangas KR, Walters EE. Lifetime prevalence and age-of-onset distributions of DSM-IV disorders in the National Comorbidity Survey Replication. Arch Gen Psychiatry 2005;62:593-602.

[4] Access Economics. The economic impact of youth mental illness and the cost-effectiveness of early intervention. Canberra: Access Economics; 2009.