Medical Journal of AustraliaVolume 209, Issue 10 p. 460-460.e1 Letter Health protection and Australian prisons, 2018 Michael H Levy, Corresponding Author Michael H Levy michaelherbertlevy@outlook.com Australian National University, Canberra, ACTCorrespondence: michaelherbertlevy@outlook.comSearch for more papers by this authorCarla J Treloar, Carla J Treloar Centre for Social Research in Health, UNSW Sydney, Sydney, NSWSearch for more papers by this author Michael H Levy, Corresponding Author Michael H Levy michaelherbertlevy@outlook.com Australian National University, Canberra, ACTCorrespondence: michaelherbertlevy@outlook.comSearch for more papers by this authorCarla J Treloar, Carla J Treloar Centre for Social Research in Health, UNSW Sydney, Sydney, NSWSearch for more papers by this author First published: 19 November 2018 https://doi.org/10.5694/mja18.00669Citations: 3Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat No abstract is available for this article.Citing Literature Volume209, Issue10November 2018Pages 460-460.e1 RelatedInformation

Purpose To provide evidence-based guidance on the optimum management of chronic pain in adult cancer survivors. Methods An ASCO-convened expert panel conducted a systematic literature search of studies investigating chronic pain management in cancer survivors. Outcomes of interest included symptom relief, pain intensity, quality of life, functional outcomes, adverse events, misuse or diversion, and risk assessment or mitigation. Results A total of 63 studies met eligibility criteria and compose the evidentiary basis for the recommendations. Studies tended to be heterogeneous in terms of quality, size, and populations. Primary outcomes also varied across the studies, and in most cases, were not directly comparable because of different outcomes, measurements, and instruments used at different time points. Because of a paucity of high-quality evidence, many recommendations are based on expert consensus. Recommendations Clinicians should screen for pain at each encounter. Recurrent disease, second malignancy, or late-onset treatment effects in any patient who reports new-onset pain should be evaluated, treated, and monitored. Clinicians should determine the need for other health professionals to provide comprehensive pain management care in patients with complex needs. Systemic nonopioid analgesics and adjuvant analgesics may be prescribed to relieve chronic pain and/or to improve function. Clinicians may prescribe a trial of opioids in carefully selected patients with cancer who do not respond to more conservative management and who continue to experience distress or functional impairment. Risks of adverse effects of opioids should be assessed. Clinicians should clearly understand terminology such as tolerance, dependence, abuse, and addiction as it relates to the use of opioids and should incorporate universal precautions to minimize abuse, addiction, and adverse consequences. Additional information is available at www.asco.org/chronic-pain-guideline and www.asco.org/guidelineswiki .

Medical Journal of AustraliaVolume 202, Issue 2 p. 77-78 Letter Meeting end-of-life care needs for patients in custody Megan Kendall MB BS, BSc, BAppSc(Hons), Corresponding Author Megan Kendall MB BS, BSc, BAppSc(Hons) [email protected] Justice Health Services, ACT Health, Canberra, ACT.Correspondence: [email protected]Search for more papers by this authorLuke Streitberg MB BS, MFM, Luke Streitberg MB BS, MFM Justice Health Services, ACT Health, Canberra, ACT.Search for more papers by this authorMichael H Levy MB BS, MPH, FAFPHM, Michael H Levy MB BS, MPH, FAFPHM Justice Health Services, ACT Health, Canberra, ACT.Search for more papers by this author Megan Kendall MB BS, BSc, BAppSc(Hons), Corresponding Author Megan Kendall MB BS, BSc, BAppSc(Hons) [email protected] Justice Health Services, ACT Health, Canberra, ACT.Correspondence: [email protected]Search for more papers by this authorLuke Streitberg MB BS, MFM, Luke Streitberg MB BS, MFM Justice Health Services, ACT Health, Canberra, ACT.Search for more papers by this authorMichael H Levy MB BS, MPH, FAFPHM, Michael H Levy MB BS, MPH, FAFPHM Justice Health Services, ACT Health, Canberra, ACT.Search for more papers by this author First published: 02 February 2015 https://doi.org/10.5694/mja14.01273Citations: 2Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinkedInRedditWechat References 1White B, Willmott L, Cartwright C, et al. Doctors' knowledge of the law on withholding and withdrawing life-sustaining medical treatment. Med J Aust 2014; 201: 229–232. https://www.mja.com.au/journal/2014/201/4/doctors-knowledge-law-withholding-and-withdrawing-life-sustaining-medical 10.5694/mja13.00217 Google Scholar 2Kariminia A, Law MG, Butler TG, et al. Factors associated with mortality in a cohort of Australian prisoners. Eur J Epidemiol 2007; 22: 417–428. 10.1007/s10654-007-9134-1 PubMedWeb of Science®Google Scholar 3Stone K, Papadopoulos I, Kelly D. Establishing hospice care for prison populations: an integrative review assessing the UK and USA perspective. Palliat Med 2012; 26: 969–978. 10.1177/0269216311424219 PubMedWeb of Science®Google Scholar Citing Literature Volume202, Issue2February 2015Pages 77-78 ReferencesRelatedInformation

Sarah Larney is supported by a National Health and Medical Research Council Early Career Fellowship (APP1035149). Potential conflict of interest: Nothing to report. To the Editor: Hepatitis C virus (HCV) infection is highly prevalent among prisoners.1 The development of new therapeutics for HCV infection has given rise to recommendations (including by one of us, S.L.) that opt‐out HCV testing be implemented in correctional settings,2 with infected individuals linked to treatment. Increasing testing and treatment of HCV infection in prisons is in line with the paradigm of “treatment as prevention”: that by reducing the pool of prevalent HCV infection through treatment, onward transmission will cease.4 There are two important issues to consider in discussions of HCV treatment as prevention in the prison context. First, prisoners are in unequal power relationships with custodial and health staff. How can we be sure that consent for HCV testing in an opt‐out environment is truly voluntary and free from coercion? Requiring prisoners to choose to not opt‐out of an HCV test, and opt‐in to an HCV test, may be an effective approach to ensuring voluntariness that also maximizes testing uptake. Furthermore, ensuring that the responsible staff do an adequate job of pretest counseling in an opt‐in setting may be a more ethical approach to increasing testing uptake than imposing a policy of opt‐out testing. Second, an important aspect of “treatment as prevention” is the converse: “prevention as treatment,” or the prevention of reinfection of treated individuals. In community settings, people successfully treated for HCV infection can usually obtain treatment for substance use disorders, including opioid substitution therapy, to assist in reducing or ceasing injecting drug use, or can access sterile needles and syringes if they do inject. Implementation of these interventions and other harm reduction measures is poor in prisons. The limited options for prisoners wishing to protect themselves against reinfection pose a significant challenge to the success of HCV “treatment as prevention” in prison settings.5 Anecdotally, prisoners are choosing to defer treatment entry in the absence of the ability to protect themselves from reinfection.

Objective: To report the prevalence of markers for HIV infection, hepatitis B and hepatitis C among Australian prison entrants. Design: Cross-sectional survey conducted over 2-week periods in 2004, 2007 and 2010. Setting: Reception prisons in New South Wales, Queensland, Tasmania and Western Australia. Participants: Individuals entering prison from the community during the survey periods. Main outcome measure: Prevalence of anti-HIV antibody (anti-HIV), hepatitis B surface antigen (HBsAg), anti-hepatitis B core antibody (anti-HBc) and antihepatitis C virus antibody (anti-HCV). Results: The study included 1742 prison entrants: 588 (33.8%) in 2004, 536 (30.8%) in 2007 and 618 (35.5%) in 2010. The age-standardised prevalence estimates for anti-HIV, HBsAg and anti-HBc were 0.4%, 2.3% and 21.7% respectively, and remained stable over the three survey periods. The agestandardised prevalence estimate for anti-HCV was 29.0%; it decreased over time (33.3% in 2004 v 23.2% in 2010; P = 0.001), and this coincided with a decrease in prison entrants reporting injecting drug use (58.3% [343/588] in 2004 v 45.3% [280/618] in 2010; P < 0.001). Among injecting drug users, the prevalence of anti-HCV was 57.2% and did not change signifi cantly over time. Of those who were anti-HCV positive, 33.7% (140/415) were unaware of their infection status, and 74.3% (185/249) of those who tested positive for anti-HBc reported that they had never had hepatitis B. Conclusions: HIV prevalence is low in the Australian prisoner population but transmission remains a risk. Despite a decrease in the proportion of prison entrants reporting injecting drug use, prevalence of hepatitis B and hepatitis C has remained high. Treatment and prevention initiatives should be prioritised for this population.

The NCCN Guidelines for Palliative Care provide interdisciplinary recommendations on palliative care for patients with cancer. These NCCN Guidelines Insights summarize the NCCN panel's discussions and guideline updates from 2013 and 2014. These include modifications/additions to palliative care screening and assessment protocols, new considerations for discussing the benefits and risks of anticancer therapy, and approaches to advance care planning. Recent updates focus on enhanced patient-centered care and seek to promote earlier integration of palliative care and advance care planning in oncology.

OBJECTIVE:To report the prevalence of markers for HIV infection, hepatitis B and hepatitis C among Australian prison entrants.DESIGN:Cross-sectional survey conducted over 2-week periods in 2004, 2007 and 2010.SETTING:Reception prisons in New South Wales, Queensland, Tasmania and Western Australia.PARTICIPANTS:Individuals entering prison from the community during the survey periods.MAIN OUTCOME MEASURE:Prevalence of anti-HIV antibody (anti-HIV), hepatitis B surface antigen (HBsAg), anti-hepatitis B core antibody (anti-HBc) and anti-hepatitis C virus antibody (anti-HCV).RESULTS:The study included 1742 prison entrants: 588 (33.8%) in 2004, 536 (30.8%) in 2007 and 618 (35.5%) in 2010. The age-standardised prevalence estimates for anti-HIV, HBsAg and anti-HBc were 0.4%, 2.3% and 21.7% respectively, and remained stable over the three survey periods. The age-standardised prevalence estimate for anti-HCV was 29.0%; it decreased over time (33.3% in 2004 v 23.2% in 2010; P = 0.001), and this coincided with a decrease in prison entrants reporting injecting drug use (58.3% [343/588] in 2004 v 45.3% [280/618] in 2010; P < 0.001). Among injecting drug users, the prevalence of anti-HCV was 57.2% and did not change significantly over time. Of those who were anti-HCV positive, 33.7% (140/415) were unaware of their infection status, and 74.3% (185/249) of those who tested positive for anti-HBc reported that they had never had hepatitis B.CONCLUSIONS:HIV prevalence is low in the Australian prisoner population but transmission remains a risk. Despite a decrease in the proportion of prison entrants reporting injecting drug use, prevalence of hepatitis B and hepatitis C has remained high. Treatment and prevention initiatives should be prioritised for this population.

The NCCN Guidelines for Palliative Care provide interdisciplinary recommendations on palliative care for patients with cancer. These NCCN Guidelines Insights summarize the NCCN panel's discussions and guideline updates from 2013 and 2014. These include modifications/additions to palliative care screening and assessment protocols, new considerations for discussing the benefits and risks of anticancer therapy, and approaches to advance care planning. Recent updates focus on enhanced patient-centered care and seek to promote earlier integration of palliative care and advance care planning in oncology.

Much of the conceptual space occupied by Justice Reinvestment theory suggests clear links with the theoretical framework of Social Inclusion and therein understandings of the social determinants of health. This article seeks to explore this mutually interested and unified relationship, and furthermore examine how their combined adoption in Australia would provide benefits for the general population as well as those in contact with the criminal justice system. Despite the existence of consistently strong links between social disadvantage and imprisonment, it is apparent the social determinants of health have yet to adequately address their implications for incarceration. Forming these links, this article will introduce and explore the notion of the social determinants of incarceration. Moreover, the importance of the social and economic imperatives to be realised through the adoption of Justice Reinvestment ideals will be argued, in turn providing explanation for why the coalescing of Justice Reinvestment and Social Inclusion is fundamentally important to consider. Therefore, we hope to prompt insightful questioning of our current institutional processes such as: Is investment in new prisons really investment in social exclusion? • Dr Jill Guthrie is a Research Fellow with the National Centre for Indigenous Studies at The Australian National University. Her research interests lie in the relationship between health and the criminal justice system. Professor Michael Levy is a public health physician with international and national experience in prisoner health as a clinician and researcher. He is currently Director of Justice Health in the Australian Capital Territory. Associate Professor Cressida Fforde is Deputy Director at the National Centre for Indigenous Studies at The Australian National University. Her research interests lie in the relationship between identity, discourse and the criminal justice system.

Prisoners are more ill than their civilian counterparts, with higher levels of addictions, mental illness, infectious diseases and dental health problems. They are intense users of precribed medications - at least while they are in custodial care. This publication brings together the experiences of 18 health professionals. Each has some experience in working with prisoner populations and each has a particular perspective on the impacts that the custodial environment has on professional practice. This publication opens opportunities for a broader appreciation of safer prescribing of medications.

Pain is a common symptom associated with cancer and its treatment. Pain management is an important aspect of oncologic care, and unrelieved pain significantly comprises overall quality of life. These NCCN Guidelines list the principles of management and acknowledge the range of complex decisions faced in the management oncologic pain. In addition to pain assessment techniques, these guidelines provide principles of use, dosing, management of adverse effects, and safe handling procedures of pharmacologic therapies and discuss a multidisciplinary approach for the management of cancer pain.

TO THE EDITOR: In June 2007 we highlighted the inconsistent application of community-accepted harm minimisation strategies, when offered to prisoners, among the various Australian jurisdictions.1 We sought information from the eight prisoner health services to assess how harm minimisation strategies were being implemented in each jurisdiction (Box). Progress has been slow, particularly in Queensland and the Northern T ritory. The positive progress, however, has been the trial of condom distribution in four Victorian prisons (not yet expanded, at the time of writing), the pharmacotherapy program in Victoria, and the introduction of buprenorphine in New South Wales, Victoria, South Australia, the Australian Capital Territory and Tasmania. Regulated exchange of injecting equipment has not yet been achieved. There have been sustained (but unconfirmed) reports of “selfregulated” tattoo parlours in at least one NSW prison (personal communication with patients, 2010– 2012). The ACT Government is actively engaging the community in a comprehensive strategy to manage bloodborne viruses at the Alexander Maconochie Centre.2 This would be the first substantive response by any jurisdiction to a 2008 national commitment of health and custodial authorities.3 Australia will adopt the United Nations Optional protocol to the convention against torture. This will bring international scrutiny to the nation’s commitment to the equivalence of services offered to Australian prisoners.4 On the health component of that commitment, we will be judged harshly.

These guidelines were developed and updated by an interdisciplinary group of experts based on clinical experience and available scientific evidence. The goal of these guidelines is to help patients with cancer experience the best quality of life possible throughout the illness trajectory by providing guidance for the primary oncology team for symptom screening, assessment, palliative care interventions, reassessment, and afterdeath care. Palliative care should be initiated by the primary oncology team and augmented by collaboration with an interdisciplinary team of palliative care experts.

These guidelines were developed and updated by an interdisciplinary group of experts based on clinical experience and available scientific evidence. The goal of these guidelines is to help patients with cancer experience the best quality of life possible throughout the illness trajectory by providing guidance for the primary oncology team for symptom screening, assessment, palliative care interventions, reassessment, and afterdeath care. Palliative care should be initiated by the primary oncology team and augmented by collaboration with an interdisciplinary team of palliative care experts.

Abstract Introduction: There are known racial disparities in cancer mortality among African American (AA) patients with shorter median survival rates compared to white patients. Utilizing evidence based clinical guidelines allows for equitable treatment of all patients and may eliminate disparities. The goal of this study was to determine whether AA patients were referred to hospice earlier in their treatment course at a tertiary academic cancer center that routinely utilizes nationally recognized treatment guidelines (i.e. – National Comprehensive Cancer Center Network, NCCN). Methods: We retrospectively analyzed 315 charts of patients referred for hospice during 2008–2009. Subjects identified as either AA or Caucasian were analyzed by race, age and socioeconomic category. Subjects residing in geographic neighborhoods corresponding to postal zip codes with median incomes of either > or ≤ $50,000 were used as a surrogate for socioeconomic status. Charts were reviewed to determine how many lines of chemotherapy were administered before hospice referral. Patients were excluded if they were referred to hospice without receiving chemotherapy. Age, number of chemotherapy regimens and socioeconomic status were compared using Wilcoxon rank-sum test within each race. The overall number of lines of chemotherapy stratified by race was compared using Van Elteren's Test. All categorical variables were summarized by year and race and compared using Fisher's exact test. Results: Patient characteristics and outcomes are as listed in the table below. There was no significant difference between the average number of lines of chemotherapy administered to AA or Caucasian patients, respectively (2.92 vs 2.62; p=0.026), and no racial difference in the percentage of patients referred for hospice discussion prior to hospice transfer [AA (92.2%) Caucasian (83.3%); p=0.36). Similarly, adherence to NCCN treatment guidelines was similar between races [AA (89.1%) Caucasian (93.1%); p=0.36]. AA patients were more likely to reside in a zip code with a lower median income (p<0.001). Interestingly, lower income Caucasian patients were statistically found to have been treated with more lines of chemotherapy prior to hospice, (2.81 compared to 2.39; p=0.04). Conclusions: In this retrospective single institution analysis, there was no evidence that AA patients or patients from lower median incomes were referred to hospice earlier than white patients or patients with higher median incomes. These results are encouraging and may be partially attributable to the use of evidence based NCCN treatment guidelines, suggesting that applying such guidelines to all patients help to eliminate racial bias and disparities in cancer care. Citation Information: Cancer Epidemiol Biomarkers Prev 2011;20(10 Suppl):A105.

n their article, Dennis et al call for timely integration of palliative care into standard oncology care and sustained collaboration between these two specialties, to provide comprehensive, individualized care for patients with advanced, incurable cancer and their families.[

The evaluation and treatment model expressed in the NCCN Distress Management Guidelines recommends that each new patient be rapidly assessed in the office or clinic waiting room for evidence of distress using a brief screening tool (the Distress Thermometer and Problem List) presented in Figure 1 (see page 369). A score of 5 or greater on the thermometer should trigger further evaluation and referral to a psychosocial service. The choice of which service should be determined by the problem areas specified on the Problem List. Patients with practical and psychosocial problems are referred to social work, emotional or psychological (excessive sadness, worry, nervousness) problems to mental health, and spiritual concerns to pastoral counselors. The primary oncology team members--doctor, nurse, and social worker--are central to making this model work. Team members collect information from the brief screening and problem list and expand it with the clinical evaluation. It is critical for at least one team member to be familiar with the mental health, psychosocial, and pastoral counseling resources available in the institution and the community. A list of the names and phone numbers for these resources should be kept in all oncology clinics and updated frequently. The first step in implementing this model is to establish a multidisciplinary committee in each institution or office responsible for 1) revising and modifying the standards of care to fit the particular clinical care setting and 2) implementing and monitoring the use of these standards. Because each institution has its own culture, standards must be implemented in ways that are compatible with each institution. The second step is to institute professional educational programs to ensure that staff is 1) aware that distress is under-recognized, 2) knowledgeable about the management of distress, and 3) aware of the resources available to treat it. It is important to have access to mental health professionals and clergy who are trained to deal with cancer-related distress. The benefits of treating distress in cancer accrue to the patients and their families, to the treating staff, and to improved efficiencies in clinic operations. Health care contracts often allow these services to "fall through the cracks" by failing to reimburse for them through either behavioral health or medical insurance. Reimbursement for services to treat psychosocial distress must be included in medical health care contracts to prevent fragmentation of services for the medically ill. For patients with cancer, integration, not separation, of mental health services and medical services is critically important. Also outcomes research studies that include quality-of-life assessment and analysis of cost-effectiveness are needed. Patients and families should be informed that management of distress is part of their total medical care. Finally, the multidisciplinary committee, office practice, or institution must be responsible for evaluating the quality of the distress management (see guidelines algorithm [page 368]), with CQI studies making an important contribution. Presently, the quality of the psychological care patients receive is not routinely monitored. Accrediting bodies have not directly examined the quality of psychosocial care, nor have they established minimal performance standards for its delivery. The panel believes that psychosocial care should and will eventually be on our institution's report cards.

The question of whether tobacco should be banned in Australian prisons raises a number of issues. Prison authorities will have to consider whether a smoking ban will trigger riots and thus endanger security as well as the rights of the non-smoker for a smoke-free environment. The article is in support of a restrictive but not a total ban on smoking in prisons.