Embedding equity in the Australian Cancer Plan: Engaging priority populations to improve equitable outcomes for all Australians

Aim: Despite Australia having some of the best cancer outcomes in the world these are not shared equitably across population groups. Disparities are strongly associated with cultural and social determinants of health including ethnicity, systemic racism, language, education, age, gender, faith, mental health, disability, health literacy and sexual orientation. The aim was to embed health equity into the Australian Cancer Plan to achieve equitable outcomes for all Australians. Method(s): An evidence-informed stakeholder engagement strategy was used to engage priority populations as follows: Led by cultural, policy, clinical and consumer experts in developing a 'health equity in cancer outcomes' framework, underpinned by an environmental scan. Driven by the health equity framework, a mixed method approach to data analysis was used to inform the engagement strategy. Examined qualitative data from community consultation and stakeholder workshops in conjunction with statistical data from population level registries. Priority populations engaged: Aboriginal and Torres Strait Islander people, people living in rural, remote and lower socioeconomic areas;people from culturally diverse backgrounds;children;adolescents;young adults;older people;LGBTQI+ community;people with disability or mental health conditions. Conducted tailored focus groups with priority population peak bodies and consumer organizations. Result(s): Preliminary findings from tailored focus groups include: the value of population focused Optimal care pathways (in addition to tumour-specific OCPs);a systems approach to consumer navigation;community organizations as facilitators of access to care;bolstering workforce capability;preserving national system innovation gains from COVID-19 telehealth, teletrials, rapid access clinics;addressing systemic racism and barriers to access (language, health literacy);delivery of strength-based, age-appropriate, culturally responsive care. Conclusion(s): Undertaking early engagement of priority populations and being guided by a health equity framework ensures that lived experiences of inequity will be addressed in the Australian Cancer Plan's 10-year ambition statements, 2 and 5 years goals, and associated actions. .

A CONCEPTUAL FRAMEWORK FOR CANCER MANAGEMENT DURING A PANDEMIC: STRATEGIES FOR SUPPORTIVE CARE

Introduction Early in the pandemic, Cancer Australia developed a conceptual framework which provided guidance on approaches to optimal cancer care in the face of significant health system challenges and risk of exposure to and harm from COVID-19. Emerging evidence during the pandemic indicated that cancer patients experienced considerable psychosocial impacts, including increased distress, depression and anxiety, and unmet information needs. Methods Evidence on the impact of the COVID-19 pandemic on cancer patients, cancer care across the care continuum, and health system capacity was reviewed, to June 2021. The conceptual framework was updated based on international and national published evidence, guidance, recommendations, and position statements. Results Supportive care strategies for cancer patients during a pandemic include extra vigilance by practitioners of screening for distress;improved communication with patients and their carers of changes to cancer care plans;provision of timely information and guidance to inform shared decision making;attention to the impact of infection control measures;, and adoption of innovative models of supportive care. Conclusions Cancer Australia's updated conceptual framework, underpinned by principles defining optimal cancer care, informs optimal supportive care across the continuum during a pandemic. It provides a planning resource for cancer care clinicians and policymakers for the current and future pandemics when supportive care needs are more paramount than ever.

REDUCTIONS IN CANCER SERVICES IN AUSTRALIA DUE TO THE PANDEMIC: IMPLICATIONS FOR THE CANCER CARE WORKFORCE

Introduction To investigate immediate and longer-term impacts of the COVID-19 pandemic on cancer care in Australia and to provide context for consideration of system-level and oncology workforce challenges, we examined provision of a range of cancer services during 2020. Methods As a marker of cancer control activity, we examined sentinel diagnostic and therapeutic procedures relating to 14 cancer types using claims data for the Medicare Benefits Schedule, a listing of medical services subsidised by the Australian Government. Results Impacts of COVID-19 on cancer-related services were observed early in the pandemic with observed number of quarterly services notably lower than expected for most cancer types nationally. Some recovery of services through to March 2021 followed with modest increases in quarterly services above that expected for some cancer types. However, sustained impacts overall for 2020 were observed for many services with 8% (163,595) fewer diagnostic and 9% (14,600) fewer therapeutic procedures observed nationally in 2020 than were expected from historical data.1 Conclusions Recovery of service numbers may indicate workload increases for an already over-burdened oncology workforce and may contribute to physical and psychological fatigue in service providers.2 Potential implications of sustained impact on services include later stage at diagnosis, increased treatment complexity and poorer outcomes. Understanding of ongoing impacts on care delivery can inform cancer control planning beyond the pandemic.

COVID-19 vaccines and cancer: Tailored information for Australia's diverse populations

Background: As the COVID-19 vaccine rollout commenced in Australia in early 2021, limited evidence was available internationally about the safety and efficacy of the COVID-19 vaccines for people with cancer, particularly because cancer patients were largely excluded from the initial clinical trials. As such, people with cancer had many questions about the COVID-19 vaccines. Australia’s Indigenous and culturally and linguistically diverse (CALD) populations experience poorer cancer outcomes and have specific information needs. As the national cancer control agency, Cancer Australia has a leadership role in providing information to support optimal outcomes for people with cancer, including Australia’s Indigenous and CALD populations. Methods: To understand and address the information needs about COVID-19 vaccines for people with cancer, Cancer Australia undertook a scoping review of national and international published literature and guidance, and sought input from key cancer control experts and consumers. In collaboration with Indigenous health and multicultural communications experts, Cancer Australia developed tailored information for Indigenous Australians and CALD populations affected by cancer. Results: Cancer Australia developed a range of information resources relating to the COVID-19 vaccines and cancer, including Frequently Asked Questions (FAQs), and multimedia promotional collateral including animation and radio advertisements. The FAQs were adapted to provide culturally appropriate messaging for Indigenous Australians with cancer and translated into the ten most spoken languages in Australia. Multi-channel social media communication promoted uptake of the resources to CALD and Indigenous communities, and between March and May 2021, the social media campaign received over 800,000 impressions and the FAQs approximately 20,000 page views. Conclusions: Throughout the pandemic, Cancer Australia has been responsive to the unique needs of the Australian cancer community. The development and dissemination of tailored information about COVID-19 vaccines for Indigenous and CALD populations is one example of how Cancer Australia aims to improve outcomes for all people with cancer in Australia. Legal entity responsible for the study: The authors. Funding: Has not received any funding. Disclosure: All authors have declared no conflicts of interest.

Understanding the impact of the pandemic on cancer services in Australia

Background: Health professionals have reported significant reductions in cancer referrals during the COVID-19 pandemic. As national real-time cancer incidence data were not available, Cancer Australia designed an approach to analysing Medicare Benefits Schedule (MBS) data to provide evidence on the impact of the pandemic on cancerrelated services in Australia. Methods: Over 500 MBS items for diagnostic and treatment procedures for the five highest incidence cancers were identified and categorised into analysis groups based on cancer type and/or similarities in type of service. Data for January to December 2020 were examined at national and jurisdictional levels, and compared to 2019 to account for normal seasonal variation. Analysis of expanded data to March 2021 for additional cancer types, age, sex, remoteness and socioeconomic status, is being undertaken. Results: There were notable reductions in services across all diagnostic and surgical procedure groups. Initial reductions were observed between March and April for diagnostic procedures and between April and May for surgical procedures. Some services showed an initial recovery in May, and some showed partial or full recovery by June and further recovery by September. For some procedure groups, analyses showed sustained reductions over the 12 months to December 2020. Similar patterns of change were observed across all Australian states and territories, with some variation by jurisdiction. While the number of cases of COVID-19 were greater during Victoria's second wave of the pandemic (July-September), the impact on service numbers was less significant, likely owing to more refined policy approaches to managing health system and workforce capacity. Conclusion: Reductions in cancer-related services may impact patient outcomes, including recurrence and survival. Understanding Editorialmaterial and organization ©2021 John Wiley & Sons Australia. Copyright of individual abstracts remains with the authors. the nature and extent of this impact, including data disaggregated by population groups, will help to determine an approach moving forward to address any poorer cancer outcomes resulting from the pandemic.

Cancer care in the time of COVID19: A conceptual framework to improve cancer outcomes during a pandemic

Background: At the start of the COVID-19 pandemic, a plan for cancer management during a pandemic did not exist. It soon became clear that without proper planning, cancer outcomes would worsen. Cancer patients are at increased risk of COVID-19 infection, morbidity, and mortality. Health sectors internationally reduced or paused non-urgent cancer care to protect cancer patients from COVID-19. However, disproportionate delays in screening, diagnosis, and treatment can unduly impact cancer outcomes, and backlogs can further burden a strained health system. Tailored approaches to cancer management are required which balance health resource availability along with the risks of exposure and benefits of treatment. Australia's relatively low COVID-19 case numbers afforded Cancer Australia an opportunity to proactively plan for optimal cancer management during this, and future, pandemics. Methods: Cancer Australia's Cancer care in the time of COVID-19: A conceptual framework for the management of cancer during a pandemic (the framework) maps evidence-based cancer care considerations in relation to a health system's capacity across acute and recovery pandemic phases, in relation to steps of the cancer care pathway. The framework promotes infection control and resource prioritisation in the context of innovative care models, triaging approaches and individualised treatment plans, underpinned by effective communication and shared decision-making. Results: The framework supports health system planning and risk-stratified approaches to guide decision-making and improve cancer outcomes. Many aspects of cancer care are recommended to continue (to varying degrees) in most pandemic phases, with modifications or pauses in some aspects of care as the pandemic curve approaches or exceeds health system capacity. Principles of the framework were employed during the second wave of COVID-19 in the Australian state of Victoria, with continuation of cancer screening programs, diagnostic investigations, and treatments wherever it was safe to do so. This resulted in reductions in cancer services and treatment being relatively smaller than in the first wave. Conclusions: Cancer management in a pandemic is not a one-size-fits-all. Countries and jurisdictions need to tailor cancer care according to the risk of the health system becoming overwhelmed. The framework guides optimal cancer care to improve outcomes for people with cancer, while minimising COVID-19 infection. As further evidence becomes available from this pandemic or in future pandemics, this framework can be refined to inform ongoing and future pandemic health system planning.

The COVID-19 pandemic led to a reduction in cancer services in Australia

Background: Australian oncologists reported dramatic decreases in cancer referrals during the pandemic. As real time data were difficult to acquire, Cancer Australia used surrogate measures to infer where reductions in medical services occurred. We analysed data available through the Medicare Benefits Schedule (MBS), a list of the medical services and professional attendances subsidised by the Australian Government, for the five highest incidence cancers: breast, colorectal, lung, prostate, and skin cancers. Methods: We identified over 500 MBS item codes for diagnostic and treatment procedures for malignancies and pre-cancerous conditions. Item codes were categorised into analysis groups based on cancer type and/or similarities in type of service. Data were examined at national and jurisdictional levels for 2020 to determine reductions during the initial COVID-19 period and to monitor subsequent recovery. Data were compared to 2019 to account for normal seasonal variation. Results: Australia's first wave of the pandemic ran from March to May, and a second wave in the state of Victoria alone ran from July to September 2020. We observed notable reductions across all diagnostic and surgical procedure groups examined, with initial reductions observed between March and April for diagnostic procedures, and a one-month delay for surgical procedures, between April and May. Some services showed an initial recovery in May, with many showing partial or full recovery by June. For some groups, analyses showed sustained reductions over the 12- month period. While COVID-19 case numbers were greater during the second wave, the impact on services was less pronounced, likely owing to more refined policy approaches to managing health system and workforce capacity. There was further recovery by September for some but not all services. Similar patterns of change were observed across all Australian states and territories, with some variation by jurisdiction. Conclusions: The pandemic has impacted the delivery of cancer care. Any potential delays in diagnoses and treatment due to these reductions in services may lead to more advanced cancer stage at diagnosis and poorer patient outcomes including recurrence and survival. Impact of COVID-19 on selected cancer services in Australia in 2020.

COVID-19 and cancer care: Embedding high-value changes into practice

Background: Health systems pressures during the COVID-19 pandemic have driven adoption of innovative models of cancer care which optimise resources and protect patients and staff. High-value changes should be identified and retained to improve resilience of cancer care. Methods: Cancer Australia reviewed the literature and consulted with oncology health professionals, cancer control experts and consumers to examine elements of cancer care that changed during the pandemic. Strategies that support high-value care and improve cancer outcomes were identified. Results: The pandemic highlighted models of care which minimise risk of infection for cancer patients, whilst optimising outcomes. Of the numerous cancer care elements that we examined, this abstract focuses on key enhancements in digital health and treatment practices. Digital health helped maintain quality and continuity of cancer care during the pandemic. Use of telehealth (for clinical and supportive care), eprescribing, and e-ordering of investigations increased, supported by national health system funding. Shared care between care settings was facilitated by rapid uptake of telehealth, ehealth records, virtual multidisciplinary team meetings and secure messaging. Treatment modifications included hypofractionated radiotherapy, transitioning to oral chemotherapy where possible, and home-based palliative care. Lower thresholds adopted for use of G-CSF with chemotherapy to reduce risk of febrile neutropenia, aimed to decrease hospital admission rates. It is important to address barriers to uptake of these high value changes. For digital health, variations in patient access to telehealth and digital health literacy can be reduced through technical and coordination support (tailored to people with diverse needs and backgrounds), with telehealth consultations offered in safe, accessible clinical or community settings. Administrative and technical burdens in health service settings can be mitigated through sustainable IT infrastructure, standardised processes for appointments, and improving staff digital health capabilities. Patient anxiety regarding changes in care plans can be mitigated through transparent, accessible, and culturally appropriate communication, documentation and shared decision-making. Clinician uncertainty in calculating risks and benefits in treatment modifications can be addressed through evidence-based standardised care procedures and riskstratification protocols. Conclusions: Many modifications to cancer care made during the pandemic can have long-term benefits and should become standard care, including enhancements in digital health and treatment practices. Strategies have been identified which enable these changes and address barriers to uptake at the system-, service-, practitioner-, and patient-level. Efforts to embed high value changes are required across the cancer control sector.

Using Close Reading as a Method for Evaluating Visualizations

Visualization research and practice that incorporates the arts make claims to being more effective in connecting with users on a human level. However, these claims are difficult to measure quantitatively. In this paper, we present a follow-on study to use close reading, a humanities method from literary studies, to evaluate visualizations created using artistic processes [Bares 2020]. Close reading is a method in literary studies that we've previously explored as a method for evaluating visualizations. To use close reading as an evaluation method, we guide participants through a series of steps designed to prompt them to interpret the visualization's formal, informational, and contextual features. Here we elaborate on our motivations for using close reading as a method to evaluate visualizations, and enumerate the procedures we used in the study to evaluate a 2D visualization, including modifications made because of the COVID-19 pandemic. Key findings of this study include that close reading is an effective formative method to elicit information related to interpretation and critique;user subject position;and suspicion or skepticism. Information gained through close reading is valuable in the visualization design and iteration processes, both related to designing features and other formal elements more effectively, as well as in considering larger questions of context and framing. © 2020 IEEE.

CHRONIC ENDOMETRITIS (CE) BY CD138 IN AN INFERTILE POPULATION: A NON-SELECTION STUDY DISCOVERING BASELINE PREVALENCE AND EFFECT ON EARLY EUPLOID EMBRYO IMPLANTATION

Objective: The diagnosis and management of CE is debated1-4. Since many patients undergoing assisted reproductive technology (ART) are only tested after treatment failure, definitive management remains imprecise. The objectives of this study were to 1) determine the prevalence of CE in infertility patients and 2) the impact of CE on euploid embryo implantation. Design: Prospective, blinded, non-selection study of patients undergoing IVF/PGT-A. Materials and Methods: All IVF/PGT-A patients cycling between 6/2019 - 3/2020 were eligible. Exclusion criteria were: 1) age 42+, 2) embryo banking/not planning ET, 3) planning untested/fresh/mosaic ET. Consented subjects underwent a standardized endometrial biopsy (EMB) at retrieval. EMB results by a single laboratory were blinded until after single euploid ET resulted in 1) +heartbeat, 2) confirmed SAB or 3) negative hCG. Primary outcome was 1) presence/absence of CE, defined as 1+ plasma cell by CD138/section and 2) ongoing pregnancy rate. Secondary outcomes included number of plasma cells/section and stratified pregnancy outcomes. Power analysis for a prevalence of 20%5 with a 95% confidence = 246 subjects. Statistical analyses included Student’s t-test, Fischer’s Exact, logistic regression with p<0.05 considered significant. Results: 104 subjects consented and underwent EMB. Seven withdrew after EMB with 97 eligible for FET. In all biopsied patients, the mean age was 36.1±3.2 years (range 28-41), 66.4% identified as Caucasian, and the most frequent infertility diagnosis was primary/unexplained infertility (42.3%). On 3/17/20, in compliance with ASRM’s COVID recommendations, all IVF/FET cycles and recruitment stopped, at which time 54/97 had undergone FET/unblinding. There were no differences in age (p=0.83), distribution of race/ethnicity (p=0.57) or infertility diagnoses (p=0.77) between transferred and untransferred patients. Due to COVID cycle stop, unblinded biopsies were reviewed for result only (not unblinded), showing 25/104 biopsies (24.0%) positive for CE with plasma cells ranging 1-34. Demographics of transferred patients showed 46 (85.2%) had a programmed ET, 50 (92.6%) with a grade 3-5Bb or higher, and a median time to ET of 56 days. Overall, 39 (72.2%) had an ongoing pregnancy. 20.4% (11/54) had CE with plasma cells ranging 1-14. Subjects with CE had an ongoing pregnancy rate of 63.6% (7/11) that was not significantly different than 74.4% (32/43) in those subjects that were CE negative (p=0.48). Logistic regression showed no difference in ongoing pregnancy when stratified by cycle type, time to ET, lining thickness, embryo day or grade, and plasma cell count. To date, the SAB rate after implantation was similar (2/7 CE positive vs. 1/32 in CE negative, p=0.07). Notably, plasma cell count had an AOR 0.822 (0.668-1.01) and the only 2 SABs seen in patients with CE had plasma cell counts >10. Conclusions: We found a baseline prevalence of roughly 24.0% in ART patients that, to date, did not affect the ongoing pregnancy rate. Further analysis with a larger cohort to examine 1) the SAB rate, 2) alternative definitions of CE, and 3) the impact of COVID are necessary. References: 1. Cicinelli, E., Matteo, M., Tinelli, R., Lepara, A., Alfonso, R., Indraccolo, U., Marrocchella, S., Greco, P. & Resta, L. (2015). Prevalence of chronic endometritis in repeated unexplained implantation failure and the IVF success rate after antibiotic therapy. Human Reproduction. 30(2): 323-330. 2. Liu Y, Chen X, Huang J, Wang C, Yu M, Laird S, Li T. Comparison of the prevalence of chronic endometrisias determined by means of different diagnostic methods in women with and without reproductive failure. Fertility and Sterility. 2018;109(5): 832-8329. 3. Bouet P, El Hachem H, Monceau E, Gariepy G, Kadoch I, Sylvestre C. Chronic endometritis in recurrent pregnancy loss and recurrent implantation failure: prevalence and role of hysteroscopy and immunohistochemistry in diagnosis. Fertility and Sterility. 2016;105(1): 106-110. 4. Vitagliano A, Saccardi C, Noventa M, Di Spiezo Sardo A, S ccone G, Ciccinelli E, Pizzi S, Andrisani A, Litta PS. Effects of chronic endometritis therapy on in vitro fertilization outcome in women with repeated implantation failure: a systematic review and meta-analysis. Fertility and Sterility. 2018;110(1): 103-112e1. 5. Masbou AK, Keefe DL, Fino ME, Hodes-Wertz B, Blakemore JK, Grifo JA. Why do euploid embryos fail to implant? The role of CD138 and chronic endometritis. Current Opinion in Gynecology and Obstetrics. 2019;2(1): 372-378.Â

Optimal cancer care in the context of COVID-19 in Australia

Background: Cancer Australia (CA), Australia’s national cancer control agency, aims to reduce the impact of cancer, address disparities and improve cancer outcomes. The approach to cancer care needs to be tailored to different phases of the pandemic and the multiple competing priorities driving healthcare. These include the likely increased risks to cancer patients of acquiring COVID-19 and of serious illness or mortality, the limitations of resources, the possibility of the healthcare system being overwhelmed and the risks of delaying cancer diagnosis and treatment. CA is in unique position to undertake this project. Methods: Australia’s Optimal Care Pathways (OCPs) for people with cancer guide the delivery of consistent, safe, high-quality and evidence-based care for people with cancer. Using published data, guidelines and recommendations, CA has developed a conceptual framework for system-wide approaches to cancer management in line with the OCPs mapped to different stages and potential severities of the COVID-19 pandemic. Results: A conceptual framework for optimal management of cancer during the COVID-19 pandemic has been developed, taking the journey from prevention and early detection through to survivorship and end-of-life care. Opportunities for evidence-based, risk-based and consensus-based decision-making about modifications to management which aim to both improve patient outcomes and minimise their exposure to, and risk of harm from, COVID-19 are mapped according to 3 acute phases (the beginning of the pandemic, approaching hospital capacity, and hospital capacity exceeded) and 2 recovery phases (early and late) of the pandemic. Second and subsequent waves of infection can also be accommodated. Some modifications to care will be of permanent value (and the pandemic has therefore driven improvement). Telemedicine is one example. Conclusions: This conceptual framework provides guidance on optimal management of cancer during the COVID-19 pandemic, is intended as a useful resource, and while designed with the Australian healthcare system and this COVID-19 pandemic in mind, is readily transferrable to any jurisdiction and for any pandemic. Lessons need to be learned for the future so that advances are not lost. Legal entity responsible for the study: Cancer Australia. Funding: Has not received any funding. Disclosure: All authors have declared no conflicts of interest.