Evaluation of a structured clinical program and formal coursework in breast surgeon training in Australia and New Zealand.

INTRODUCTION: Breast surgeon training has been restructured since the inception of Breast Surgeons of Australia and New Zealand Inc. (BreastSurgANZ) in 2010. In 2016 a voluntary online course with a contemporary curriculum for breast surgery was initiated and taken up by the majority of post-fellowship trainees (PFTs). This article reports on PFT's perceptions of these major changes. METHODS: A 46-item online survey was sent to the 56 PFTs enrolled in 2015-2017. The survey canvassed PFT's views on aspects of the two-year training program, the Graduate Certificate in Breast Surgery (GCBS) and the role of BreastSurgANZ in training. RESULTS: 33/56 participants responded. The training program was rated positively with variation in satisfaction levels depending on operating experience and quality of training between clinical placements. The majority of respondents endorsed restricting numbers of training positions. GCBS students valued the clinical knowledge and structured format of the course. A range of diverse, often opposing, opinions were expressed on the appropriate role of BreastSurgANZ in training and accreditation. DISCUSSION: The dissonance caused by variability in training exposure and perceived mentor quality in different sites was the most important finding. The GCBS was well regarded by all students but time constraints and costs prevented some PFTs from undertaking the course. Standardisation of mandatory requirements for full BreastSurgANZ membership was identified as an issue for further consideration. CONCLUSION: This evaluation illuminates the challenges of providing consistently high quality breast surgical training. Many of the issues raised are being addressed by BreastSurgANZ.

The impact on Australian women of lack of choice of breast reconstruction options: A qualitative study.

BACKGROUND: Many studies have demonstrated the positive impact of breast reconstruction (BR) on women following mastectomy for breast cancer. However, women's preferences for BR are not always considered by surgeons prior to mastectomy. The aim of this research is threefold: to document the negative impact lack of choice has had on some Australian women; to explore potential reasons for the absence of informed discussion; and to develop a prompt list of discussion topics to aid informed decision making. METHODS: This research is part of a larger study using semistructured telephone or face-to-face interviews with women with breast cancer, surgeons, and health professionals to explore ways of improving access to BR. This article focuses on responses from all 22 women who reported negative BR experiences and seven of 31 surgeons who had made comments relevant to limiting BR discussion and choice. RESULTS: The impact of a lack of information or choice at the time of mastectomy was often extreme and long-term. Breast surgeons are the gate keepers to accessing BR but too often appeared to limit women's choices. Interviews revealed cases where BR was not offered prior to mastectomy, even though it was available locally; where BR was not available locally, but patients were not informed about BR options available in other locations; where only delayed BR options were discussed; and where the type of BR being offered did not match patient preferences. CONCLUSION: We have suggested essential BR discussion points to be raised with all clinically eligible women interested in considering BR.

Colorectal cancer screening: why immunochemical fecal occult blood tests may be the best option.

BACKGROUND: There are many test options available for colorectal cancer screening. The choice of test relates to the objectives of those offering or considering screening. DISCUSSION: While all screening programs aim to detect disease early in order to improve the length and/or quality of life for the individual, some organizations and individuals prefer screening tests that offer the opportunity for cancer prevention. Others favor maximizing participation or the opportunity for shared decision-making, including discussion of information on test quality and availability. We propose three additional objectives for screening: minimizing harms, optimizing economic efficiency and maximizing equity of access to screening. SUMMARY: Applying these objectives to colorectal cancer screening, we advocate the use of immunochemical FOBTs as the preferred screening strategy, as it satisfies all three of these important objectives.

Costs and cost-effectiveness of full implementation of a biennial faecal occult blood test screening program for bowel cancer in Australia.

OBJECTIVE: To examine the costs and cost-effectiveness of full implementation of biennial bowel cancer screening for Australian residents aged 50-74 years. DESIGN AND SETTING: Identification of existing economic models from 1993 to 2010 through searches of PubMed and economic analysis databases, and by seeking expert advice; and additional modelling to determine the costs and cost-effectiveness of full implementation of biennial faecal occult blood test screening for the five million adults in Australia aged 50-74 years. MAIN OUTCOME MEASURES: Estimated number of deaths from bowel cancer prevented, costs, and cost-effectiveness (cost per life-year gained [LYG]) of biennial bowel cancer screening. RESULTS: We identified six relevant economic analyses, all of which found colorectal cancer (CRC) screening to be very cost-effective, with costs per LYG under $55,000 per year in 2010 Australian dollars. Based on our additional modelling, we conservatively estimate that full implementation of biennial screening for people aged 50-74 years would have gross costs of $150 million, reduce CRC mortality by 15%-25%, prevent 300-500 deaths from bowel cancer, and save 3600-6000 life-years annually, for an undiscounted cost per LYG of $25,000-$41,667, compared with no screening, and not taking cost savings as a result of treatment into consideration. The additional expenditure required, after accounting for reductions in CRC incidence, savings in CRC treatment costs, and existing ad-hoc colonoscopy use, is likely to be less than $50 million annually. CONCLUSIONS: Full implementation of biennial faecal occult blood test screening in Australia can reduce bowel cancer mortality, and is an efficient use of health resources that would require modest additional government investment.

Fifteen years of bowel cancer screening policy in Australia: putting evidence into practice?

Bowel cancer kills over 4000 Australians each year. From the late 1980s to October 2005, research evidence guided the development of bowel cancer screening policy proposals, but political, financial and institutional constraints restricted implementation options. Since 2006, the Australian Government has provided a limited bowel cancer screening program, based on what the government deems it can afford, rather than on evidence of what is required to implement a successful population-based screening program. Even a partial program can be implemented in an evidence-based way, and failure to do so threatens to undermine the potential public health gains of a national bowel cancer screening program. To realise the expected public health gains from a national bowel cancer screening program, bowel cancer screening policy should return to its evidence-based beginnings, starting with an analysis of Australian age-specific cost-effectiveness data.