Economic evaluation of a skin cancer prevention program in Australia : past achievements and future prospects

Objectives
Australia has the highest incidence of skin cancer in the world. Skin cancer prevention campaigns have been implemented in Australia for over two decades. The most notable is under the brand name, SunSmart. The aim of the current study is to assess the cost-effectiveness of SunSmart in the past and the potential cost-effectiveness of an ongoing national SunSmart program with optimal investment in the future.

Methods
An economic evaluation from a health sector perspective was conducted using the reduction in skin cancer incidence attributable to the SunSmart program modelled as the primary end-point. Historical SunSmart program expenditures were obtained from three representative states in three latitude zones, covering different levels of UVR exposure. Melanoma incidence rates from the three representative state cancer registers were used to model the health outcomes. Program effectiveness was assessed by the comparison between the well-resourced SunSmart state (Victoria) and the under-invested states (New South Wales and Queensland). Non-Melanoma Skin Cancer (NMSC) was modelled based on national survey results. 2003 was chosen as the reference year and future costs/outcomes over a 20 year time horizon were discounted at 3%.
The future level of investment in a national SunSmart was chosen to strengthen current practice by increasing current investment to a realistic and achievable level. This conservative increase in investment (expressed as ‘$ per capita’) reflected the investment level that has been achieved in Victoria over sustained periods. To model the potential cost-effectiveness of an upgraded national SunSmart program, a conservative approach was taken, whereby the same magnitude of effectiveness from 1988 to 2003 was applied to future skin cancer incidence.

Results
SunSmart in Victoria has saved 22,300 life-years, averted 27,900 disability-adjusted life-years(DALYs)(discounted) since its introduction in 1988 and achieved an incremental cost-effectiveness ratio (ICER) of $AUD 680 per life-year saved (LYS) and $AUD 540 per DALY averted. When the cost-offset from the estimated reduction in skin cancer treatment costs were taken into account, SunSmart achieved ‘dominance’. The net cost of SunSmart in the past was an estimated saving of $AUD 93 million. An upgraded national SunSmart for the next 20 years would save 91,000 life-years and avert 122,000 DALYs (discounted), involving an increased investment level from the current $AUD 0.07 per capita to the historical average of $AUD 0.28 per capita. The ICER for the upgraded SunSmart program was estimated at $AUD 940 per LYS and $AUD 700 per DALY averted. When the cost-offset is included, the program achieves dominance with a cost saving of $AUD 115 million – an estimated $AUD 2.32 return for every dollar invested between 2003 and 2022.

Conclusions
This study demonstrates that a sustained modest investment in skin cancer control is likely to be excellent value-for-money. While the available data base is certainly not prefect, key parameters would have to change dramatically for this conclusion to be challenged.

Participation, relational justice and social identity in cervical cancer screening

Extending existing health literature by drawing on social and community psychology, this thesis represents the first attempt to explore the conceptualisation of 'participation' in cervical cancer screening. Quantitative and qualitative findings suggested that women's experiences of 'patient participation' and 'voice opportunity' were important and related to various social processes and variables in this health context. Using four case studies, the professional portfolio demonstrates a biopsychosocial approach to assessment and intervention as used by a provisional health psychologist working with clients with intellectual disabilities in order to promote sexual health.

Association between sexual behavior and cervical cancer screening

Background: Not much is known about whether women who follow Pap testing recommendations report the same pattern of sexual behavior as women who do not.
Methods: Data come from part of a larger population-based computer-assisted telephone survey of 8656 Australians aged 16–64 years resident in Australian households with a fixed telephone line (Australian Longitudinal Study of Health and Relationships [ALSHR]). The main outcome measure in the current study was having had a Pap test in the past 2 years.
Results: Data on a weighted sample of 4052 women who reported sexual experience (ever had vaginal intercourse) were analyzed. Overall, 73% of women in the sample reported having a Pap test in the past 2 years. Variables individually associated with Pap testing behavior included age, education, occupation, cohabitation status, residential location, tobacco and alcohol use, body mass index (BMI), lifetime and recent number of opposite sex partners, sexually transmitted infection (STI) history, and condom reliance for contraception. In adjusted analyses, women in their 30s, those who lived with their partner, and nonsmokers were more likely to have had a recent Pap test. Those who drank alcohol at least weekly were more likely to have had a recent test than irregular drinkers or nondrinkers. Women with no sexual partners in the last year were less likely to have had a Pap test, and women who reported a previous STI diagnosis were more likely to have had a Pap test in the past 2 years.
Conclusions: There are differences in Pap testing behavior among Australian women related to factors that may affect their risk of developing cervical abnormalities. Younger women and regular smokers were less likely to report a recent test. Screening programs should consider the need to focus recruitment strategies for these women.

Women's perceptions of familial aspects of breast cancer

Women’s understanding of familial aspects of breast cancer was examined using both focus groups and interviews. The studies covered issues related to perceptions of breast cancer risk factors, perceived breast cancer risk, understanding of risk information, and family history of breast cancer as a risk factor. Study 1 consisted of four focus group discussions with women from the general community. Study 2 comprised ten face-to-face interviews with women who had a family history of breast cancer. The results in combination indicate a fairly high level of awareness of family history as a risk factor for breast cancer. However, the definition of a familial history of breast cancer differed between the groups, with those without a family history being more inclusive than those with such a history. The paper concludes with suggestions for use by those developing resources materials for those with a familial history of breast cancer.

The psychological impact of a cancer diagnosis on families: the influence of family functioning and patients' illness characteristics on depression and anxiety

A diagnosis of cancer is a very stressful event for the patients and their families. Patients, partners and other family members can suffer from clinical levels of depression and severe levels of anxiety and stress reactions. The similarity in levels of distress between patients and partners and patients and offspring suggests that there are common factors that impact on families' distress levels. The current study examined levels of depression and anxiety in newly diagnosed adult patients (n = 48) and their adult relatives (n = 99). Family functioning and patients' illness characteristics were identified as factors that might impact on families' depression and anxiety. Results from multilevel models indicated that family functioning was important. Families that were able to act openly, express feelings directly, and solve problems effectively had lower levels of depression. Direct communication of information within the family was associated with lower levels of anxiety. Aside from differences anxiety due to cancer type, patients' illness characteristics appear to be risk factors in patients' but not relatives' depression and anxiety. The results from the current study suggest that researchers and clinicians need to be family-focused as cancer affects the whole family, not just the patient.

An investigation into the incidence of obesity and underweight among adults with an intellectual disability in an Australian sample

Reports suggest that 7% to 18% of Australian adults are obese and a further 16% to 55% are overweight. Studies from other countries have indicated that obesity among people with an intellectual disability may be at least, or even more, prevalent. Prevalence rates range from 28% to 59%. The aim of the current study was to investigate the weight distribution of an Australian sample of people with an intellectual disability using Body Mass Index (BMI) to classify males and females, and Kelly and Rimmer's (1987) Percentage of Body Fat (PBF) formula to also classify males. Forty-one females and 52 males with a mild to severe intellectual disability were assessed. The correlation between BMI and PBF for males was r=.89. BMI classifications revealed a higher percentage of females as overweight (41.4%) and obese (36.6%) compared to overweight males (30.8%) and obese males (30.8%). There were more underweight males (7.6%) than females (4.9%). There was no relationship between living environment and weight classifications on the BMI. The PBF formula indicated that 73% of the males were classified as obese. The possibility of misclassification using the BMI and the need for weight interventions are discussed.

Lipids and FA analysis of canine prostate tissue

It is widely reported that an association exists between dietary fat intake and the incidence of prostate cancer in humans. To study this association, there is a need for an animal model where prostate carcinogenesis occurs spontaneously. The canine prostate is considered a suitable experimental model for prostate cancer in humans since it is morphologically similar to the human prostate and both humans and dogs have a predisposition to benign and malignant prostate disease. In this study, the FA and lipids profiles of the normal canine prostate tissue from nine dogs were examined. The total lipid content of the canine prostate tissue was 1.7±0.5% (wet weight). The lipid composition analysis using TLC-FID showed that the two major lipid classes were phospholipids and TAG. Total FA, phospholipid, and TAG FA analysis showed that the major FA were palmitic acid (16∶0), stearic acid (18∶0), oleic acid (18∶1), linoleic acid (18∶2n−6), and arachidonic acid (20∶4n−6), The n−3 FA were present at <3% of total FA and included α-linolenic acid (18∶3n−3) (in total and TAG tissue FA), EPA (20∶5n−3) (not in TAG), and DHA (22∶6n−3) (not in TAG). The n−3/n−6 ratio was 1∶11, 1∶13, and 1∶8 in total, phospholipid, and TAG FA, respectively. This study shows the canine prostate has a low level of n−3 FA and a low n−3/n−6 ratio. This is perhaps due to low n−3 content of the diet of the dogs. FA analysis of dogfoods available in Australia showed that the n−3 content in both supermarket and premium bran dogfoods was <3% (wet weight), and the n−3/n−6 ratio was low.

α-linolenic acid and the risk of prostate cancer. What is the evidence?

Purpose
Several studies have examined the association between polyunsaturated fatty acids and prostate cancer risk. We evaluated the evidence on the association between the essential polyunsaturated fatty acid, known as α-linolenic acid, and the risk of prostate cancer in humans.
Materials and Methods
We comprehensively reviewed published studies on the association between α-linolenic acid and the risk of prostate cancer using MEDLINE.
Results
A number of studies have shown a positive association between dietary, plasma or red blood cell levels of α-linolenic acid and prostate cancer. Other studies have demonstrated either no association or a negative association. The limitations of these studies include the assumption that dietary or plasma α-linolenic acid levels are positively associated with prostate tissue α-linolenic acid levels, and measurement errors of dietary, plasma and red blood cell α-linolenic acid levels.
Conclusions
More research is needed in this area before it can be concluded that there is an association between α-linolenic acid and prostate cancer.

Dietary patterns, insulin resistance, and incidence of type 2 diabetes in the Whitehall II study

OBJECTIVE—We examined the associations of objectively measured sedentary time and physical activity with continuous indexes of metabolic risk in Australian adults without known diabetes.

RESEARCH DESIGN AND METHODS—An accelerometer was used to derive the percentage of monitoring time spent sedentary and in light-intensity and moderate-to-vigorous–intensity activity, as well as mean activity intensity, in 169 Australian Diabetes, Obesity and Lifestyle Study (AusDiab) participants (mean age 53.4 years). Associations with waist circumference, triglycerides, HDL cholesterol, resting blood pressure, fasting plasma glucose, and a clustered metabolic risk score were examined.

RESULTS—Independent of time spent in moderate-to-vigorous–intensity activity, there were significant associations of sedentary time, light-intensity time, and mean activity intensity with waist circumference and clustered metabolic risk. Independent of waist circumference, moderate-to-vigorous–intensity activity time was significantly beneficially associated with triglycerides.

CONCLUSIONS—These findings highlight the importance of decreasing sedentary time, as well as increasing time spent in physical activity, for metabolic health.

Glucose indices, health behaviors, and incidence of diabetes in Australia: the Australian diabetes, obesity and lifestyle study (AusDiab)

OBJECTIVE--We examined the associations of objectively measured sedentary time and physical activity with continuous indexes of metabolic risk in Australian adults without known diabetes.

RESEARCH DESIGN AND METHODS--An accelerometer was used to derive the percentage of monitoring time spent sedentary and in light-intensity and moderate-to-vigorous-intensity activity, as well as mean activity intensity, in 169 Australian Diabetes, Obesity and Lifestyle Study (AusDiab) participants (mean age 53.4 years). Associations with waist circumference, triglycerides, HDL cholesterol, resting blood pressure, fasting plasma glucose, and a clustered metabolic risk score were examined.

RESULTS--Independent of time spent in moderate-to-vigorous-intensity activity, there were significant associations of sedentary time, light-intensity time, and mean activity intensity with waist circumference and clustered metabolic risk. Independent of waist circumference, moderate-to-vigorous-intensity activity time was significantly beneficially associated with triglycerides.

CONCLUSIONS--These findings highlight the importance of decreasing sedentary time, as well as increasing time spent in physical activity, for metabolic health.