If Caitlin Delaney hadn’t pushed for genomic testing and off-label therapies, she might not have been around to share her insights on The Medical Podcast this week.

As a health professional she also had the benefit of health literacy and a personal assertiveness that may have well also helped her be at her daughter’s 10th birthday.

“There were lots of ‘sliding door’ moments. If I hadn't asked a certain question or pushed for a different answer or gotten a second or third opinion, then the outcome would be very different,” she says.

The epicentre of Ms Delaney’s survival is genetic testing. She says it’s critical because it opens the doorway to emerging new treatments, personalized medicine and clinical trials.

“These are critical for all cancer patients, but especially for rare cancer patients whose treatment options may be limited,” Ms Delaney said

Ms Delaney was diagnosed with stage 4 clear cell ovarian cancer nearly seven years ago. She is enthusiastic about PROSPECT a new cancer treatment pathway that provides genomic testing to Australians with rare or incurable cancers, and then provides access to any clinical trials and off-label therapies that might make a difference.

PROSPECT cancer screening program is a clever collaboration between University of New South Wales, NSW government and a whole range of players in the Australian medical research sector.

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Professor David Thomas leads Omico, the not-for-profit which runs PROSPECT’s cancer screening program. He is optimistic about PROSPECT bringing a bit more equity to cancer treatment for those with rare cancers who often miss out on trials or are and also for remote patients.

“Regional and rural Australia is very important to us and we're specifically trying to promote the program and work with our clinical colleagues in regional cancer centers.

“That specifically applies also to Aboriginal and Torres Strait Islander cancer patients. Rural and regional patients, as well as Indigenous cancer patients, have demonstrably worse outcomes. We don't want them to be left behind,” he says.

For the 150 people diagnosed each day with a rare cancer, it’s a new pathway that can make the difference and not just in the future. Professor Thomas says the program is not a philanthropic exercise with no connection with patient interests.

“The pace of research progress is so great that it's now creating options for patients in real time rather than for some future benefit.

“I would encourage us to think about research as just another part of the way of our armamentarium when we try to treat diseases like cancer,” he says.

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With so much to learn in so little time, managing LGBTQI+ patients isn’t yet high on the priority list at medical schools.

Dr Asiel Adan Sanchez is a GP and clinical tutor at the university of Melbourne. He knows first-hand that clinical environments can be off putting for people who are queer, trans and gender diverse. He’s also created a solution for that called Wavelength: a learning tool that builds clinician skills and makes general practices safer for LGBTQI+ folk.

Dr Sanchez gives a quick masterclass on the simple and practical ways to take away the awkward interactions that occur in many medical environments. They say a very common example is when taking a sensitive history and asking about gender affirmation procedures.

“A lot of clinicians really struggle with asking those questions and often the language that they use is quite inappropriate. ‘Have you had the operation?’ for example. A patient might get this question all the time outside, in the real world, and if you don't explain to the patient what the rationale behind asking those questions is, it can be really distressing for them,” says Dr Sanchez.

Dr Sanchez provides a graduated approach to inquiring about gender affirmation surgery, after building rapport through simple ways such as using correct pronouns.

“I often tell medical students to fall back on the skills that they already have around cultural competency to build that rapport with the person. For example, you might be talking about work and family and what the patient does at home. Then you can ask ‘By the way, are there any pronouns that you'd like me to use?’ And that's an organic and simple approach,” they say.

Wavelength training module is now managed by the Australian Medical Student Association (AMSA), which is advocating to incorporate the content into Australian medical school curricula.

Medical student Sophia Nicolades has researched the LGBTQI+ health curriculum gap. They found that, on average, there were between zero and two hours across the whole medical degree dedicated to LGBTQI+ health.

“We also found that the groups with the poorest healthcare outcomes were also the least present in our curricula – those being trans people, intersex people, bisexual people, and those with intersectional experiences such as First Nations people and folks with disability,” Mx Nicolades said.

Dineli Kalansuriya, medical student and chair of AMSA Queer, is also working to improve the medical curricula at Australian universities.

“We would also love for some practising doctors to take part in the Wavelength module and let us know if they feel that it's relevant, if it's representative of the presentations that they've been seeing as well,” she said.

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The number of spinal fusions performed in Australia has skyrocketed over the past few decades, with the number of privately funded procedures far outstripping those done in the public system.

Spinal fusions, which help stabilise the spine by surgically joining two or more vertebrae together, can be used following traumatic injury, or to help correct scoliosis in children. But the most common use for spinal fusions is in degenerative conditions of the spine.

This episode of The Medical Republic Podcast explores when this procedure should be considered, and why we are seeing such a large increase in the number of these procedures being performed.

Dr Ashish Diwan, director of the Spine Service at St George Hospital in New South Wales, says there are several considerations to be weighed before undertaking a spinal fusion, including the duration, intensity and frequency of back pain; whether other treatment options have been tried; and what the patient wants.

Dr Diwan has sympathy for GPs with patients who are considering undergoing a spinal fusion, which is far from a straightforward decision: “It's like trying to get married. If you're in doubt, don't do it.”

The decision not to do surgery can be equally challenging, according to Dr Diwan.

“There is also an incredible lack of evidence as to what you do for a person who continues to suffer. The alternatives [drugs, spinal cord stimulators or radiofrequency ablations] are not very clear … none of them stack up when you start dealing with people who have pain of a chronic nature.”

There are many reasons for the spike in the number of spinal fusions being performed, according to Professor Ian Harris, an orthopaedic surgeon and researcher from the University of NSW.

“There is an aging of the population, but [now] there are more so called ‘indications’ for spine surgery,” he tells the podcast. “The techniques of doing them have developed in a way that there's now lots of different ways you can do spine fusions.”

Several reasons also exist for why more privately, rather than publicly, funded procedures are being done. But Professor Harris feels the inclusion of MRI scans on the MBS is glaringly obvious one.

This presents a fine line to walk between using imaging to rule out potential pathologies and jumping at shadows and operating unnecessarily on age-related changes. This reinforces the need for clear discussions with patients about any imaging findings.

“Just having a scan doesn't hurt anyone. It's what you do with the results that can harm people.”

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