Pregnancy and breast cancer, advanced dementia medication and smarter athletes
Think:Health cultivates and articulates the best in health research and news.
The following program, which aired on Sunday 11th October 2015, features:
- the experiences of women who are diagnosed with breast cancer while pregnant (01:13);
- medicating advanced dementia patients and how a palliative care approach to medication could reduce unnecessary treatment (12:15); and
- smart athletes and how GPS technology is transforming the approach to identifying high calibre players (21:05).
Guests:
- Professor Elizabeth Sullivan - Associate Dean (Research) at the UTS Faculty of Health.
- Domenica DiSalvo - PhD student at the UTS Faculty of Health.
- Dr Mark Watsford - Senior Lecturer in exercise and sports science at the UTS Faculty of Health.
Presenter:
- Ellen Leabeater, 2ser
Listen online 107.3 2ser (audio length 30 mins)
Transcript:
[Music]
[Introduction]
Facilitator: Hello, and welcome to Think Health where we cultivate and articulate the best in new health research. I'm Ellen Leabeater and you're tuned in to 2SER, 107.3.
Today on the show how much medication should patients with advanced dementia be given, and are the best AFL players the ones that run the most?
[Excerpt of interview]
Male: But, typically, what you might see is a more experienced team, or the more experienced players, actually covering less distance and doing things smarter rather than doing things faster.
[End of excerpt]
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Facilitator: First on the program breast cancer during pregnancy. It can be a delicate juggling act as clinicians battle to save both the mother and the unborn child's life. Do you undergo chemotherapy while pregnant…do you wait until you give birth…will this harm my baby… are all thoughts that can go through a mother's mind.
New research has looked at the incidents of breast cancer in pregnant women and examined what treatment they decide to undergo. The research also asked women who had survived breast cancer in pregnancy about their experiences.
Elizabeth Sullivan was one of the study authors. She's also the Professor of Public Health at the University of Technology Sydney. Professor Sullivan started off by explaining how common a first diagnosis of breast cancer is in pregnancy.
[Excerpt of interview]
Elizabeth Sullivan: Breast cancer in pregnancy is very uncommon. We estimate it to be about - around eight per 100,000 births. So in Australia we'd expect to see around 25 cases per year.
Facilitator: Is breast cancer easy to find in pregnant women?
Elizabeth Sullivan: Look, no. I think one of the challenges of breast cancer in pregnancy is that women often get changes in their breasts throughout pregnancy so, often, when they present with a lump to their doctor, the common things are thought about as being the problem first. So, often, there is a delay - or this is what we've found in our study - in women having the breast lump identified as breast cancer.
Facilitator: What's the characteristics of women who have breast cancer during pregnancy?
Elizabeth Sullivan: So we did a national study looking - based in Australia and New Zealand - looking at first diagnosis of breast cancer during pregnancy. What we found is probably what you would expect: about three quarters of the women were aged between 30 and 39. Most of the women hadn’t smoked previously, and most of them were accessing care through the public hospital sector.
Facilitator: What you're saying is that breast cancer - it does increase with your age, and if women are delaying pregnancy, they're the women who are more likely to have breast cancer during pregnancy.
Elizabeth Sullivan: Yes, I think that's absolutely right, that what you see is, with older women having first babies, and also with women also deferring children, we see that the majority of the cases really are in women aged 35 and older.
Facilitator: The interesting thing to come out of this study was that women noticed that something wasn't right with their breast before they were pregnant.
Elizabeth Sullivan: Yes. So what we found was that a lot of women had breast symptoms prior to being diagnosed. So when we looked at it, four out of five women actually had breast symptoms. One of the things that became clear in the interviews with the women was that, often, when women discovered a lump there was a bit of a delay or an issue around being believed from their perspective, so they might have to present or re-present to a health care provider before they were on a pathway to being diagnosed.
One of the things that they really felt was important was that there would be - first of all, that if they present with a lump it's important for it to be assessed and, secondly, to have prompt referral for diagnostic tests.
Facilitator: When these lumps were discovered - when the cancer was discovered - was it - were they serious cancers?
Elizabeth Sullivan: Yes. What we found was that nearly 60 per cent of the cancers were what are called tumour grade three, which is a high grade.
Facilitator: What treatment is available to women who have breast cancer during pregnancy?
Elizabeth Sullivan: Look, the standard set of treatments are available to women with breast cancer in pregnancy. Really depends upon what gestational timing during pregnancy that they are diagnosed but, certainly, the women in our study had both surgery, chemotherapy, depending upon the type of cancer and what the clinicians had suggested.
Facilitator: When you're talking about the gestational period when the breast cancer was diagnosed, how does that affect treatment?
Elizabeth Sullivan: Yeah, look, I think the timing of the diagnosis does make a difference to the strategy for the treatment. I'm not an oncologist, but from what we've seen in the study, certainly, those who are diagnosed in early pregnancy are much more likely to have some form of surgery - be it breast conservation or mastectomy - followed by some sort of therapeutic regime that might include chemotherapy; whilst those who are diagnosed late in the third trimester - so close to when they would be going to give birth - often have induction so that they deliver just a little bit early. So we see a high rate of pre-term birth, babies born at less than 37 weeks. Then they have treatment afterwards.
Facilitator: Chemotherapy during pregnancy has got to be - it's a lot of chemicals going through your body. What goes through the woman's mind when that is offered as an option?
Elizabeth Sullivan: Yes, I think that's one of the really challenging parts about being diagnosed with breast cancer during pregnancy, is what is the impact of potentially life saving chemotherapy on the women and the baby. Certainly, I think one of the really positive things coming out of this study is that what we saw was that the babies really didn't seem to have any adverse effects, and they were - had surprisingly good outcomes.
Facilitator: So what were the birth outcomes like for the children, for the babies?
Elizabeth Sullivan: Look, the birth outcomes were surprisingly good and, I think, consistent with some of the international literature. We found a very high rate of pre-term births. Now, part of that was actually planned pre-term birth, so that women were induced so that they could start chemotherapy post-delivery.
So we found nearly 44 per cent of the babies were born pre-term, which is a very high rate, 25 per cent were low birth weight. There was really - about one in three was admitted to a high care ward, so a high dependency unit or intensive care, but we saw no deaths and we saw almost all the babies discharged home in a short period of time.
Facilitator: Another area of your study looked at the co-ordination of care between oncologists and obstetricians. How did the clinicians organise that?
Elizabeth Sullivan: What we also did was we interviewed a series of women who'd had breast cancer in the previous five years during pregnancy to try and learn more about their experiences during pregnancy and how that impacted the pregnancy.
One of the key findings of that was, I suppose, communication. It was communication both between their health care providers - so the oncologists and the maternity care providers - and also communication to the woman. I think we saw a very mixed picture where either women experienced very good communication and well co-ordinated care. Then, in other cases, women didn't have quite the same positive experience, where there was a lot of uncertainty and differences in the opinions they were getting from the different health care providers.
One of the things that the women noted that had really helped them during their pregnancy was having access to a breast care nurse. That seemed to allow a much better communication pathway and gave them a sense of empowerment.
Facilitator: The other interesting thing was the vaginal birth rates among this cohort.
Elizabeth Sullivan: Yeah. The vaginal birth rates were good. We had about two thirds of women gave birth vaginally, with quite a large proportion of those women being a planned induction with the idea that treatment would occur after delivery. Only about one in three women had a caesarean section.
Facilitator: Why do clinicians tend not to do a caesarean when they're treating women with breast cancer?
Elizabeth Sullivan: I think the issue around caesarean section is that it's an operation and that, if women are going to go straight in to having chemotherapy or other forms of care, that there is the issue about the healing of the wound and the recovery post-delivery. That's why a vaginal birth would be preferred.
Facilitator: So what can - what have we learned from this study? What can clinicians do to better provide service to women who are pregnant and have breast cancer?
Elizabeth Sullivan: I think the critical things coming out of this are really that if women present with breast symptoms during pregnancy that they need to be assessed and with prompt referral, if needed. It's very critical that in - during pregnancy that there is a clear plan if someone gets diagnosed with gestational breast cancer, that both the oncologist and the maternity services work together to make sure that both the plan and the information and the counselling is there throughout, because the experiences women had was very varied.
I think the positive things coming out of it were that in this small case series we see that the baby outcomes are very good, and almost surprisingly good. So I think that's a very positive message.
Facilitator: Another positive was that breast - a lot of women still ended up breast feeding after this.
Elizabeth Sullivan: Yes, that's right. I think another positive is that - you're right - that following delivery of the baby, that over half the women continued to breast feed. I think that shows a level of wellness and also connection with the baby post-delivery.
Facilitator: That was Elizabeth Sullivan, Professor of Public Health at the University of Technology Sydney.
You're listening to Think Health on 2SER. Coming up next how to reduce unnecessary medication for advanced dementia patients.
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Facilitator: Welcome back to Think Health on 2SER.
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Dementia is a feared and tragic disease which causes huge pain to sufferers and their families. Often, in Australia, aged care patients in the later stages of dementia are heavily medicated as a result of an approach known as active prescribing.
[Dominique de Salvo], PhD student in the Faculty of Health at UTS, is looking into the benefits of palliative care, which is a less aggressive treatment for aged care patients with advanced dementia. Palliative care has the potential ensure patients are as comfortable as possible by eliminating unnecessary treatment measures.
She spoke with Sam King to explain her take on providing the best possible care for these patients.
[Excerpt of interview]
Dominique de Salvo: Prescribing medications isn't always the answer. At that end stage we need to make sure that they're as comfortable as possible, not in pain. A lot of the time these individuals with advanced dementia are kept on many medications that are used to treat secondary conditions rather than treat the symptoms.
Sam King: How did you personally come across this issue? Is it something that you've had in mind for a while? Or when did you know that this is the sort of thing that you wanted to do?
Dominique de Salvo: Well, I started in medical science to begin with, and it's just like a natural progression. I just moved into the health faculty. I was really interested in dementia and medications. There's actually a larger study going on at the moment called the IDEAL Project which is looking at people with advanced dementia, so I attached myself to this larger national initiative and was focussed on the medication side of the IDEAL Project.
Sam King: Look, as I mentioned before - and I'm going to say it again - I'm actually employed as a Webstercare technician at a pharmacy and, look, I've seen firsthand the sheer quantity of medications that some nursing home clients consume. We're talking hundreds of pills each day.
Dominique de Salvo: That's right, a lot of medications.
Sam King: It's insane.
Dominique de Salvo: Yep.
Sam King: Does your research look to reducing the quantity of medications that these people are taking?
Dominique de Salvo: Yes, definitely, because the palliative approach is trying to reduce the number of medications that might not be appropriate at this later stage of dementia, such as cardiac medications, any kind of medications that are trying to actively improve other conditions, that it might not be appropriate at that end stage, where...
Sam King: Where do you draw the line though? How do you decide what is necessary and what isn't?
Dominique de Salvo: Well, that's the problem. It's such a difficult decision to determine when a medication is inappropriate or not and deciding when and whose decision that is.
Sam King: Is it also a question of finding different medications for existing conditions, or even improving how doctors prescribe medications that interact with each other? Does that play into it as well?
Dominique de Salvo: So a part of this IDEAL Project - I was able to look at all these medication charts that residents with advanced dementia were on. Basically, there are a lot of criteria that are used to identify inappropriate prescribing in the elderly, but these are not catered for individuals who have dementia and require a palliative approach. So there's one criteria that has been identified for advanced dementia that's used.
It's not particularly - it definitely does need work. You can't just determine whether a medication is inappropriate or not. You obviously need to take into consideration the individual, and that's where it becomes really difficult. You can't just make a stock standard type of criteria and follow that because it's not going to work for every individual.
Sam King: What do you propose to do in order to address the issue? Is it a question of more organisation, more communication between doctors?
Dominique de Salvo: Oh well, I think it requires a multidisciplinary approach. So at the moment there is this national initiative called the Residential Medication Management Review. This is federally funded. This is a review system that requires the GP, the resident's GP, and a pharmacist and any other health professionals that might be important to determine whether medications are appropriate.
This is used in many aged care facilities, but we're trying to - my PhD tries to - at the moment - sorry - I'm going to - I'm starting to interview pharmacists to gain their opinion on how this reviewing system can be improved for residents with advanced dementia.
Sam King: What feedback have you had so far?
Dominique de Salvo: Well, I haven’t started yet.
Sam King: True [laughs].
Dominique de Salvo: I start very soon. Maybe there are - maybe having a section that flags the resident with - as having advanced dementia. Sometimes it might not be quite obvious that the resident has advanced dementia and requires this palliative approach, so looking at medications for comfort care rather than active prescribing.
Sam King: What impact would you say that this area of research has on the families of patients with dementia because, obviously, dementia is an illness which impacts hugely on the family and friends of these people?
Dominique de Salvo: That's right.
Sam King: So how would you say that this can help?
Dominique de Salvo: Well, I think if we try to improve decisions around medication prescribing, making sure that we include families in that decision, with other health professionals that can really alleviate any stress that a resident or - that a family member might have, because it's very - it'd be so challenging for a family member to see their loved one struggle.
I think also it's very challenging for even GPs to determine when it's appropriate to take a resident off a medication at that stage. Even broaching that subject with a family member would be very challenging when the family member has seen that that medication has helped their family member. At this stage - at the later stage - when it might do more harm than good with all the side effects that these aggressive medications can have - it might be better to take the resident off, and that can be a challenging decision.
Sam King: Can you think of any particular medications that are prescribed right now that cause a lot of discomfort to patients with dementia?
Dominique de Salvo: Well, at the moment, looking at the data they have so far, antipsychotics are a large issue at the moment. Obviously, antipsychotics are used to treat behavioural symptoms of dementia, and they are - they can be appropriate in the earlier to mid stages of dementia, but when residents are still on antipsychotics at the end stage they really - they're not appropriate anymore because they don't have those behavioural issues that you see earlier on.
We've seen that almost half the residents that we have with advanced dementia are still on an antipsychotic, and this is in line with a report that was just recently released by Alzheimer's Australia, which saw antipsychotics as still an issue in Australia, especially Australia. It's seen as an issue compared to other countries which seem to have a handle on it a little bit better.
Sam King: If you had your way and you could instantly change the industry right now, how would it - what's the best case scenario for you?
Dominique de Salvo: Oh, just making sure that there's a reviewing system in place that flags the resident as having dementia and advanced dementia so that all parties involved can identify that prescribing needs to be in line with palliative prescribing, and make sure that prescribing is in line with what's best for the resident, to improve quality of care and making sure that they're as comfortable as possible.
[End of excerpt]
Facilitator: That was Dominique de Salvo, PhD student at UTS, talking there to Sam King.
You're listening to Think Health on 2SER. Stay with us. We'll be back shortly.
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Facilitator: Hello, and welcome back to Think Health on 2SER. Hope your morning is going smoothly. If you have ever watched team sports you may be tricked into thinking the best players are the ones that run the most. However, the opposite is true. GPS technology is increasingly showing that the best players are the ones that run the least.
Mark Watsford is a senior lecturer in the Faculty of Health at the University of Technology Sydney. He has been looking at how the distances AFL players run relate to their calibre as a player.
[Excerpt of interview]
Mark Watsford: It varies depending on the position they play. The average is around about 12 to 13 kilometres. That's obviously spread across four quarters of 20 minutes plus stoppage time, so it's about 105 minutes or so. It can be down as low as six, seven kilometres for some of the fixed positions, and up as high as even 17, 18 kilometres in a game.
Facilitator: So are the best teams the ones that necessarily run the most?
Mark Watsford: Well, it would potentially come across to a spectator that team that's seemingly all over the park and running fast, able to get to the ball quickly - it would seem that they dominate the game but, typically, what you might see is a more experienced team, or the more experienced players, actually covering less distance and doing things smarter rather than doing things faster.
So the notion of experience and playing smarter can trump - or can win out over out and out physical prowess. That's not to say you can just not bother training physical prowess. There needs to be a minimum level of physical capacity to play team sport at the highest levels, but it doesn't necessarily mean that you need to run the fastest to win the game.
Facilitator: Wouldn't the experienced players also be the older players, and therefore they don't have as much energy to, say, run around the field for younger players?
Mark Watsford: Yeah. Obviously, with experience - with age comes experience and vice versa. There are cases of some pretty good physical specimens of older people, but I guess, in general, you might see their - the overall physical capacity is somewhat reduced in the older players; but to the point where some of the younger players - and when we're talking about the first and second year players - just because they're 18 or 19, that doesn't mean that they are in the peak of physical condition. It could well be that the three to six year players - so you're talking the 21 to 26 year olds - potentially, they would form the benchmark in terms of the physical capacities.
Facilitator: So what's the difference in performance for high calibre and low calibre players?
Mark Watsford: So from the research that we've been conducting, the coaches give a rating for how well they think the player performed in that game. That is based on their position specific requirements, so were they required to tag a player, were they required to be on - do something in the forward pocket, something specific like that, so how well did the player undertake their role?
Then it's a score that's rated out of 20. Then we can look at dividing - what we did in this research was divide them into the high calibre players and the low calibre players. So we were able to get a feel for players who were performing their task - what did they do in terms of their movement demands - and those that didn't do so well, what did they do or what didn't they do.
So by dividing them into - not just in half. We didn't just say that the top half were the highs. We divided them into smaller groups and just took the upper percentiles and the lower percentiles, and we were able to get a good feel for the differences in running from those particular positions.
Once again, it seemed like the higher calibre players didn't do the bulk of the physical work, that they were actually - once again, the experienced players - so they're tactically superior and, potentially, technically more proficient as well.
Facilitator: Because AFL involves more than just running - you've got to be able to kick. You've got to be able to throw. You've got to be able to tackle. So I can see why conserving energy would be necessary to do all that, but are we focussing too much on running and ignoring the other skills in the game?
Mark Watsford: Throughout a weekly training program there is a lot of time devoted to the skill components. Certainly, there's a benchmark level to reach AFL standard to make it through the draft camp and to be drafted. There's a minimum standard that all players can perform these tasks proficiently. Then it's being able to perform those tasks under conditions of fatigue and to perform sprints under repeated conditions and whilst executing these technical capabilities with precision.
That is of utmost importance in the game. When it comes late in the fourth quarter, when you've been playing for 95 minutes already, something like that, you need to be able to have the physical capacity to perform those tasks to the perfect precision and perfect output.
So training - by boosting physical capacity and understanding the demands of the game, then you're able to specifically contrive either match scenarios to practice in, in the training pitch, or we're building capacity to have the players have the ability to perform those tasks with precision at the end of a game, when it's needed.
Facilitator: You said that the average punter probably looks to see if their team is running a lot as an indicator of whether they're doing well, but - and, as you said, that's not necessarily the case - but do coaches understand the link between running and performance?
Mark Watsford: Oh, without a doubt, yeah. The coaches are the absolute gold standard of judging performance in matches. As exercise scientists we would never question the role of the coach in being able to make a judgement on players. I think it would be naive of us to think that we know more about the physical - and the demands of the game than a coach. So I'm very confident that coaching staff are able to distinguish between the technical, the tactical and the physical side of things. They know when someone might be running around without that technical involvement. They're very - they're well aware of that.
[End of excerpt]
Facilitator: Mark Watsford, a senior lecturer in the Faculty of Health at the University of Technology Sydney, ending that report.
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Facilitator: If you'd like to find out more about that story, or listen to any of our past programs, head to our website at 2ser.com\thinkhealth. This show is produced with the support of the University of Technology Sydney Faculty of Health. Please remember that you should not consider the contents of this show medical advice, and you should consult your physician if you have any concerns.
I'm Ellen Leabeater. This has been Think Health. See you next week for more in health research and news.
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