Background Advances in breast cancer (BC) care have reduced mortality, but their impact on survival once diagnosed with metastasis is less well described. This systematic review aimed to describe population-level survival since 1995 for de novo metastatic BC (dnMBC) and recurrent MBC (rMBC). Methods We searched MEDLINE 01/01/1995-12/04/2021 to identify population-based cohort studies of MBC reporting overall (OS) or BC-specific survival (BCSS) over time. We appraised risk-of-bias and summarised survival descriptively for MBC diagnoses in 5-year periods from 1995 until 2014; and for age, hormone receptor and HER2 subgroups. Findings We identified 20 eligible studies (14 dnMBC, 1 rMBC, 5 combined). Potential sources of bias in these studies were confounding and shorter follow-up for the latest diagnosis period For dnMBC, 13 of 14 studies reported improved OS or BCSS since 1995. In 2005-2009, the median OS was 26 months (range 24-30), a median gain of 6 months since 1995-1999 (range 0-9, 4 studies). Median 5-year OS was 23% in 2005-2009, a median gain of 7% since 1995-1999 (range-2 to 14%, 4 studies). For women >= 70 years, the median and 5-year OS was unchanged (1 study) with no to modest difference in relative survival (range:-1.9% (p = 0.71) to +2.1% (p = 0.045), 3 studies). For rMBC, one study reported no change in survival between 1998 and 2006 and 2007-2013 (median OS 23 months). For combined MBC, 76-89% had rMBC. Three of four studies observed no change in median OS after 2000. Of these, one study reported median OS improved for women <= 60 years (1995-1999 19.1; 2000-2004 22.3 months) but not > 60 years (12.7, 11.6 months). Interpretation Population-level improvements in OS for dnMBC have not been consistently observed in rMBC cohorts nor older women. These findings have implications for counselling patients about prognosis, planning cancer services and trial stratification. (c) 2022 The Author(s). Published by Elsevier Ltd.

Guidelines now discourage opioid analgesics for chronic noncancer pain because the benefits frequently do not outweigh the harms. We aimed to determine the proportion of patients with chronic noncancer pain who are prescribed an opioid, the types prescribed and factors associated with prescribing. Database searches were conducted from inception to 29 October 2018 without language restrictions. We included observational studies of adults with chronic noncancer pain measuring opioid prescribing. Opioids were categorized as weak (e.g. codeine) or strong (e.g. oxycodone). Study quality was assessed using a risk of bias tool designed for observational studies measuring prevalence. Individual study results were pooled using a random‐effects model. Meta‐regression investigated study‐level factors associated with prescribing (e.g. sampling year, geographic region as per World Health Organization). The overall evidence quality was assessed using Grading of Recommendations Assessment, Development and Evaluation criteria. Of the 42 studies (5,059,098 participants) identified, the majority ( n = 28) were from the United States of America. Eleven studies were at low risk of bias. The pooled estimate of the proportion of patients with chronic noncancer pain prescribed opioids was 30.7% (95% CI 28.7% to 32.7%, n = 42 studies, moderate‐quality evidence). Strong opioids were more frequently prescribed than weak (18.4% (95% CI 16.0–21.0%, n = 15 studies, low‐quality evidence), versus 8.5% (95% CI 7.2–9.9%, n = 15 studies, low‐quality evidence)). Meta‐regression determined that opioid prescribing was associated with year of sampling (more prescribing in recent years) ( P = 0.014) and not geographic region ( P = 0.056). Opioid prescribing for patients with chronic noncancer pain is common and has increased over time.

Abstract Aims Between December 2001 and July 2015 Australian women with HER2-positive metastatic breast cancer (MBC) accessed trastuzumab in combination with taxane chemotherapy or as monotherapy via the government funded Herceptin Program (HP); we characterise their treatment patterns and survival outcomes. Methods This retrospective, whole-of-population cohort study used linked dispensing, medical services, and death records. We stratified patients into three year-of-trastuzumab-initiation groups: 1. 2001-2002 (may include patients accessing trastuzumab in later lines); 2. 2003 - October 2006 (likely first-line treated but prior to trastuzumab availability for early breast cancer (EBC)); and 3: October 2006–June 30 2015 (most representative of contemporary practice). Patients were observed until death or censored at June 30 2016. We estimated duration of trastuzumab therapy from the initial dispensing date for MBC until 30 days after the last dispensing. We considered a gap of ≥90 days between trastuzumab dispensings a separate course of treatment. We estimated overall survival (OS) as the time from first trastuzumab dispensing until death from any cause. We used Kaplan-Meier methods to estimate the total duration of trastuzumab therapy and OS. We used dispensing dates of cancer medicines to determine concomitant treatments and used claims for echocardiography and MUGA scans to determine the timing of cardiac monitoring. Results 5,895 patients accessed trastuzumab for MBC. Median age at trastuzumab initiation was 57 years (IQR: 48 – 66). 800 patients (22%) from Group 3 also received trastuzumab for EBC. Treatment details and OS are tabulated: Overall (n = 5,895)Group 1 (n = 495)Group 2 (n = 1,709)Group 3 (n = 3,691)Median time on trastuzumab for MBC, first course, months (IQR)13.2 (5.7 – 26.6)9.2 (3.8 – 22.5)12.3 (5.4 – 23.3)14.0 (6.1 – 29.8)Median OS from first trastuzumab dispensing for MBC, months (IQR)30.3 (13.4 – 68.7)19.8 (8.9 – 38.8)27.5 (12.5 – 58.9)34.6 (15.1 – 82.8)Patients initiating trastuzumab, n (%): monotherapy1,571 (27)226 (46)625 (37)720 (20)+ taxane3,150 (53)157 (32)800 (47)2,193 (59)+ hormonal therapy763 (13)47 (9)169 (10)561 (15)+ non-taxane chemotherapy376 (6)65 (13)115 (7)217 (6)Cardiac assessment: at baseline (60 days prior to 30 days following trastuzumab initiation)3,721 (63%)189 (38%)831 (49%)2,701 (73%)during treatment3,324 (56%)150 (30%)778 (46%)2,396 (65%) Conclusions Our real-world estimates of OS for each patient group are both similar to and shorter than those from clinical trials published during similar time periods. Group 3 median OS is 6 months shorter than the control arm of the CLEOPATRA study (34.6 v 40.8 months) while median duration of first trastuzumab course was 4 months longer (14.0 v 10.4 months), suggesting patients continue trastuzumab beyond progression. In Group 3, 25% of patients died within 15 months of starting trastuzumab, 50% survived beyond 3 years and 25% survived beyond 7 years. These estimates will be useful for clinicians discussing expected survival time with patients in routine practice. Although the cardiotoxicity of trastuzumab is well recognised, baseline cardiac assessment was not universal, even in the most recent cohort. Citation Format: Daniels B, Kiely BE, Lord SJ, Houssami N, Pearson S-A. Real-world use and outcomes of trastuzumab for HER2+ metastatic breast cancer in Australia: Analysis of the herceptin program, 2001-2015 [abstract]. In: Proceedings of the 2017 San Antonio Breast Cancer Symposium; 2017 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2018;78(4 Suppl):Abstract nr P2-12-01.

BACKGROUND Debate abounds regarding the most appropriate candidates to admit to medical school. This paper examines whether there is any advantage to admitting 'graduate' entrants over secondary school leavers on selected medical school and practice outcomes.AIM To compare the medical school experiences, research and academic achievements and practice outcomes of graduates who entered 1 medical school in Australia directly from high school (secondary school entry) to those of graduates who entered with tertiary level education (tertiary entry).DESIGN AND METHODS Cross-sectional study using a mail-out survey to graduates from the first 16 graduating years (1983-98 inclusive) of the University of Newcastle Medical School.RESULTS Secondary school entrants were, on average, 8 years younger than tertiary entrants and were less likely to have received rural-based schooling. However, there were no differences with respect to gender or type of secondary school attended (public or private). Motivations for studying medicine did not generally differ according to entry type, except that more secondary students were motivated by parental expectations and more tertiary entrants were motivated by the need for professional independence and the desire to prevent disease. A greater proportion of tertiary entrants experienced stress at medical school. However, secondary students experienced more stress due to doubts about being a doctor, while tertiary entrants experienced more stress due to lack of leisure time, finances and balancing commitments. There were no significant differences between the groups in terms of academic performance (as measured by the award of medical school honours) or research outcomes (as measured by completion of a research degree during or after medical school training, publication of scientific papers or holding career posts in the research sciences). There were no differences in career positions held by clinicians, choice of general practice or another specialty as a career, practice location (rural or urban) or employment sector (public or private).CONCLUSION There is no clear advantage, at least on the outcomes measured in this study, to limiting medical school entry to either those candidates from secondary school or those with tertiary backgrounds. Medical schools could reasonably broaden their selection criteria to include more graduate entry candidates in addition to secondary school leavers without compromising medical school and practice outcomes.

Aims This study examined the relationship between the performance of first year medical students at the University of Newcastle, Australia, and admission variables: previous educational experience, and entry classification (standard - academic or composite, Aboriginal and Torres Strait Islander, or overseas), age and gender.Methods Admission and demographic information was obtained for students who entered first year medicine at Newcastle between the years 1994 and 1997 inclusive. Academic performance was measured according to results of first assessment ('satisfactory' vs. 'not satisfactory') and the final assessment of the first year ('satisfactory' vs. 'not satisfactory'). Logistic regression was used to examine the relationship between predictor variables and outcomes.Results Assessment and admissions information was obtained for 278 students, 98% of all students who entered the medical course between 1994 and 1997. Regression analysis of first assessment indicated that Aboriginal and Torres Strait Islander and overseas students were significantly more likely to be 'not satisfactory' than all other students (RR = 3.1,95% CI: 1.4-6.7 and RR = 1.5, 95% CI: 1.2-1.8, respectively). Analysis of final assessment indicated these two student groups were also significantly more likely to be 'not satisfactory' than all other students (RR = 4.5, 95% CI: 1.4-13.5 and RR = 3.5, 95% CI: 1.2-10.8, respectively). At first assessment, students entering via the standard academic pathway and older students were less likely to be 'not satisfactory' (RR = 0.6, 95% CI: 0.5-0.7 and RR = 0.8, 95% CI: 0.7-0.9, respectively). However both these differences were not evident at final assessment. There were no significant relationships between performance in first year and the remaining variables.Conclusions Aboriginal and Torres Strait Islander, and overseas medical students had academic difficulties in the first year of the course, suggesting the need for extra course support. The result may reflect the educational and other obstacles these students must overcome in order to enter and progress through their medical degree. More research is warranted to explore the extent to which these differences persist throughout the medical degree.

AIM:The primary aim of the study was to compare the practice outcomes of doctors who graduated from a non-traditional, problem-based medical school (University of Newcastle) with those of graduates from a traditional programme (University of Sydney), matched randomly on the background characteristics of graduation year, age, gender, and rural primary and secondary school education. Our secondary aim was to differentiate admission from curricular influences by comparing the outcomes of Newcastle and Sydney graduates who entered medical school under similar admission criteria ('traditional academic' entry).DESIGN:Nested case-control analysis in a retrospective cohort study.METHODS:A validated mail-out survey was distributed to all Newcastle and Sydney graduates registered to practise in the state of New South Wales, Australia.OUTCOME MEASURES:Current main occupation (clinician or other), clinical career choice (family medicine and psychiatry or other specialties), practice location (urban or rural) and employment sector (public or private).RESULTS:A total of 513 Newcastle respondents (68% of the original, eligible Newcastle sample) were each matched randomly with a Sydney respondent according to the four background characteristics. Medical school background was not related to main occupation; over 90% of all graduates were employed in clinician positions. A greater proportion of Newcastle than Sydney graduates were either training or qualified in family medicine or psychiatry rather than in other specialties. The school of graduation was not related to practice environment; fewer than 20% of all graduates were working in rural locations and around 25% were employed in the public sector. There were no differences in outcome between Newcastle and Sydney graduates who had entered medical school under similar academic criteria.CONCLUSION:Our study suggests that initial selection procedures of medical school candidates with particular background characteristics and attributes may influence practice outcomes. Further research is required to confirm these findings.

OBJECTIVES:To examine the self-reported influences on intern prescribing practice.DESIGN:Qualitative interviews with a cross-sectional cohort.PARTICIPANTS AND SETTING:Ten interns practising in two urban teaching hospitals in New South Wales, Australia.RESULTS:The interns identified a number of factors that improve their confidence and perceived competence and allow them to extend their existing skills. These were approachable, available and up-to-date teachers (most often registrars and subspecialty nurses and pharmacists); timely, relevant and practical teaching (such as interactive bedside teaching); concise and widely accepted resources (such as prescribing pocket guides); and a constructive manner on the part of senior staff for dealing with prescribing errors. Interns also identified influences that are detrimental to confidence, conflict with their perceptions of appropriate prescribing and inhibit learning and skills acquisition. These were unapproachable, physically and mentally remote teachers (most often consultants); theoretical, inconsistent and irrelevant teaching (such as grand rounds or didactic education sessions); inconsistent and inaccessible resources; and a confrontational and accusatory way of dealing with prescribing errors. The added pressures of time, hospital hierarchies and the indirect influence of drug company promotion also impeded acquisition of good prescribing habits.CONCLUSIONS:At a critical time in skills development, interns encounter many forces that can potentially impact on prescribing practices in both positive and negative ways. Our data contribute to the understanding of the multifaceted learning environment of interns and may be useful in providing a foundation for prescriber education programmes tailored to the specific needs of junior doctors.

The objectives of the study were to report the development of a core curriculum that details the clinical conditions medical students should be able to manage upon graduation; and to canvass the opinion of interns (first-year postgraduate doctors) regarding their perceptions of the level of skill required to manage each condition. Literature relating to core curriculum development and training of junior medical officers was reviewed and stakeholders in the education and training of medical students and junior doctors in the state of New South Wales, Australia (intern supervisors, academics, registrars, nurses and interns) were consulted. The final curriculum spanned 106 conditions, 77 'differentiated' and 29 'undifferentiated'. Four levels of skill at which conditions should potentially be managed were also identified: 'Theoretical knowledge only'; 'Recognize symptoms and signs without supervision'; Initiate preliminary investigations, management and/or treatment without supervision'; and 'Total investigation, management and/or treatment without supervision'. The list of conditions in the curriculum was converted to a survey format and a one-in-two random sample of interns (n = 193) practising in New South Wales who graduated from the state's three medical schools were surveyed regarding the level of skill required for managing each clinical condition at graduation. A total of 51.3% of interns responded to the survey. Interns felt they should be able to initiate preliminary investigation, management and/or treatment for most conditions in the curriculum, with more than half acknowledging this level of management for 53 of the differentiated and 28 of the undifferentiated conditions. It is concluded that developing core curricula in medical education can involve multiple stakeholders, including junior doctors as the consumers of educational experiences. The data gathered may be useful to medical schools revising their curricula.

CONTEXT:Research on the factors affecting progress in medical schools has typically focused on mainstream (non-Indigenous Australian, non-international) students in traditional, didactic programmes. These results may not be applicable to students, particularly those from culturally diverse backgrounds, undertaking problem-based learning courses. OBJECTIVE:This study used qualitative methodology to explore and compare factors affecting progress for mainstream Australian students (non-Indigenous Australian, non-international) and international students (full fee-paying students who had relocated countries to study) in a problem-based learning medical course. Intervention strategies were devised on the basis of the participants' experiences. METHODS:Six focus group discussions were conducted (three with mainstream Australian and three with international participants). Transcripts of these discussions were coded and analysed independently by two researchers and discussed until consensus was attained. RESULTS:Participants identified both positive and negative experiences related to the course structure, which were consistent with previous findings. The participants' experiences demonstrated a relationship between sense of 'belongingness' to the medical school community, participation in learning opportunities and progress through the course. CONCLUSIONS:The results suggest that interventions aimed at reducing barriers to progress need to promote students' confidence, motivation and subsequent participation in course learning opportunities. These results have application to other problem-based learning courses particularly those which face the challenge of providing an optimal learning environment for students from diverse backgrounds.

Aim: To investigate knowledge about and attitudes to cardiopulmonary resuscitation (CPR), and to determine whether written information about CPR alters knowledge and choices made.Design: Questionnaire-based survey before and immediately after provision of written information describing CPR and its risks and benefits.Subjects and setting: All health professionals (803) and competent inpatients (260) in a tertiary care hospital (John Hunter Hospital, Newcastle, New South Wales, Australia) in June 1994.Main outcome measures: CPR knowledge scores and choice scores (number of hypothetical clinical scenarios in which CPR would be chosen) before and after provision of information about CPR.Results: Response rates were 64% (health professionals) and 58% (patients). Patients had limited awareness of procedures involved in CPR, while both patients and health professionals overestimated its success rates. Mean knowledge scores increased after provision of information: for patients, from 6.4 out of 18 (95% confidence interval [CI], 6.0-6.9) to 10.4 (95% Cl, 9.9-11.1); and for health professionals, from 11.9 (95% CI, 11.7-12.1) to 13.9 (95% CI, 13.7-14.2). In contrast, mean choice scores decreased after provision of information: for patients, from 5.3 out of 12 (95% CI, 4.7-5.7) to 4.4 (95% Ct, 3.9-4.8); and for health professionals, from 4.1 (95% CI, 3.9-4.2) to 3.5 (95% CI, 3.3-3.7).Conclusion: Our results imply that people understand and use prognostic information to make decisions about CPR. To make autonomous judgements, patients and health professionals need better education on CPR outcomes.

Objective To compare the attitudes towards community medicine of first and final year students from two Australian medical schools.Method In 1995, medical students from Newcastle University (a problem-based, community-oriented curriculum) and Adelaide University (a more traditional lecture-based curriculum) were asked to complete the Attitudes to Community Medicine questionnaire. This is a valid and reliable 35 item survey assessing six key domains of community medicine. The two medical schools differ in their methods of selection and curriculum delivery, and also in curriculum content.Results Response rates averaged 95% for first year and 81% for final year students. Students selected into both medical schools were found to have positive attitudes with respect to most aspects of community medicine. However, those entering Newcastle had more positive attitudes toward community medicine overall than their Adelaide counterparts. They also scored more positively on subscales relating to holistic care and evaluation of health care interventions. Students who were older and female scored more positively on some subscales, but correction for age and gender did nor change the conclusions about medical school differences.Conclusion This study suggests that selection criteria, and probably curriculum style and emphasis, have an influence on the attitudes that medical students possess and later develop toward community medicine.

This study examined the utility of the domain assessment measures used in the final 2 years at Newcastle medical school in predicting performance ratings in the first year of postgraduate training (internship). Performance ratings were obtained from the clinical supervisors of two graduating classes of the University of Newcastle medical students during their five terms of internship. Three or more ratings were obtained from 57% of interns. Univariate analysis indicated that scores for three of the five domains (professional skills; identification, prevention and management of illness; self-directed learning) were significantly positively correlated with intern performance ratings. Multivariate analysis indicated that only the domain assessing identification, prevention and management of illness was predictive of higher intern performance ratings. The results support the notion that there is some value in the domain assessment model used at Newcastle in predicting the performance of junior doctors.

OBJECTIVE:To examine the opinions of patients and healthcare professionals regarding the process of making decisions about cardiopulmonary resuscitation (CPR).DESIGN AND PARTICIPANTS:A cross-sectional survey of 511 healthcare professionals (doctors, nurses and allied health professionals) (64% response rate) and 152 patients (58% response rate) at the John Hunter Hospital, Newcastle, New South Wales, in June 1994.MAIN OUTCOME MEASURES:Opinions on who should be involved in CPR decision making; what issues are important when making the decision; and how these decisions should be communicated.RESULTS:80% (95% confidence interval [CI], 72%-86%) of patients and 99% (95% CI, 98%-100%) of healthcare professionals (P<0.001) thought patients' views should be taken into account when making CPR decisions. More patients (29%; 95% CI, 22%-38%) than healthcare professionals (14%; 95% CI, 11%-17%) indicated that doctors should be the main decision makers. Two-thirds of respondents regarded the patient's wishes, diagnosis and quality of life as important factors. Most respondents (82%) felt comfortable discussing CPR, but only 29% (95% CI, 22%-37%) of patients and 57% (95% CI, 52%-61%) of healthcare professionals had actually discussed CPR with others (P<0.001). More than half of all respondents preferred to express their wishes about CPR in writing (47% [95% CI, 39%-55%] of patients, 69% [95% CI, 64%-73%] of healthcare professionals; P<0.01); the others preferred to tell a family member or close friend. Most patients (60%; 95% CI, 52%-68%) and healthcare professionals (85%; 95% CI, 81%-88%) wanted their views in their medical records (P< 0.001).CONCLUSION:Most patients want to be involved in CPR decision making and many want some form of advance directive. Although there are some differences in opinions between patients and healthcare professionals, both perceive decision making at the end of life as a shared process, primarily involving the patient and doctor.

Objective: To examine the influence of sociodemographic background, medical school background, general practice characteristics and attitudes towards preventive medicine on the screening recommendations of New South Wales (NSW) general practitioners (GPs).Methods: From the NSW Medical Board Register, a sample was obtained of all GPs who graduated between 1983 and 1987 from the University of Newcastle and a random 1-in-3 sample of GPs from the Universities of Sydney and NSW. Two questionnaires were mailed consecutively.Participants: 363 GPs (56% response rate) who completed questionnaires suitable for analysis.Main outcome measure: A composite screening score for assessing agreement with standard screening guidelines. The score was derived by allocating points to the screening intervals that GPs recommended for 13 screening tests. A score of 39 indicated maximum agreement with guidelines.Results: 87% of GPs reported being aware of standard screening guidelines. For most screening tests, there was a discrepancy between GPs' recommendations and those of the guidelines. Composite screening scores ranged from 8-38. There were significantly higher screening scores for graduates of Newcastle versus Sydney and NSW university medical schools combined (adjusted mean, 28.0 versus 25.9; P=0.0436), group versus solo GPs (adjusted mean, 26.3 versus 25.6; P=0.0092) and GPs in rural versus urban locations (adjusted mean, 27.9 versus 25.6; P=0.0049).Conclusions: GPs' recommendations for screening are not always consistent with standard guidelines, despite an awareness of them. Research is needed into the variation with which different screening tests are ordered.

A questionnaire to measure attitudes toward community medicine held by general practitioners was designed, and a 35-item scale with a Likert response format was constructed. The Attitudes Toward Community Medicine scale consists of six subscales relating to key areas of community medicine. The final scale is valid and reliable for group comparisons, with alpha coefficients ranging from α=0.54 to α=0.84. The instrument may be used to evaluate the effectiveness of community medicine teaching, to describe differences in beliefs of practitioners and to estimate changes in attitudes over time.