The impact of delayed diagnosis and treatment due to COVID-19 on Australian thyroid cancer patients: a qualitative interview study

OBJECTIVES

The study aims to investigate the perceptions of patients with thyroid cancer on the potential impact of diagnosis and treatment delays during the COVID-19 pandemic.

DESIGN

This study involved qualitative semi-structured telephone interviews. The interviews were transcribed verbatim, analysed using the thematic framework analysis method and reported using the Consolidated Criteria for Reporting Qualitative Research.

SETTING

Participants in the study were treated and/or managed at hospital sites across New South Wales and Victoria, Australia.

PARTICIPANTS

17 patients with thyroid cancer were interviewed and included in the analysis (14 females and 3 males).

RESULTS

The delays experienced by patients ranged from <3 months to >12 months. The patients reported about delays to diagnostic tests, delays to surgery and radioactive iodine treatment, perceived disease progression and, for some, the financial burden of choosing to go through private treatment to minimise the delay. Most patients also reported not wanting to experience delays any longer than they did, due to unease and anxiety.

CONCLUSIONS

This study highlights an increased psychological burden in patients with thyroid cancer who experienced delayed diagnosis and/or treatment during COVID-19. The impacts experienced by patients during this time may be similar in the case of other unexpected delays and highlight the need for regular clinical review during delays to diagnosis or treatment.

The impact of breast density notification on psychosocial outcomes in racial and ethnic minorities: A systematic review

BACKGROUND

High breast density is an independent risk factor for breast cancer and decreases the sensitivity of mammography. This systematic review synthesizes the evidence on the impact of breast density (BD) information and/or notification on women's psychosocial outcomes among women from racial and ethnic minority groups.

METHODS

A systematic search was performed in March 2023, and the articles were identified using CINHAL, Embase, Medline, and PsychInfo databases. The search strategy combined the terms "breast", "density", "notification" and synonyms. The authors specifically kept the search terms broad and did not include terms related to race and ethnicity. Full-text articles were reviewed for analysis by race, ethnicity and primary language of participants. Two authors evaluated the eligibility of studies with verification from the study team, extracted and crosschecked data, and assessed the risk of bias.

RESULTS

Of 1784 articles, 32 articles published from 2003 to 2023 were included. Thirty-one studies were conducted in the United States and one in Australia, with 28 quantitative and four qualitative methodologies. The overall results in terms of breast density awareness, knowledge, communication with healthcare professionals, screening intentions and supplemental screening practice were heterogenous across studies. Barriers to understanding BD notifications and intentions/access to supplemental screening among racial and ethnic minorities included socioeconomic factors, language, health literacy and medical mistrust.

CONCLUSIONS

A one-size approach to inform women about their BD may further disadvantage racial and ethnic minority women. BD notification and accompanying information should be tailored and translated to ensure readability and understandability by all women.

Effectiveness of hybrid digital breast tomosynthesis/digital mammography compared to digital mammography in women presenting for routine screening at Maroondah BreastScreen: Study protocol for a co-designed, non-randomised prospective trial

BACKGROUND

Digital breast tomosynthesis (DBT) for breast cancer screening has been shown in international trials to increase cancer detection compared with mammography; however, results have varied across screening settings, and currently there is limited and conflicting evidence on interval cancer rates (a surrogate for screening effectiveness). Australian pilot data also indicated substantially longer screen-reading time for DBT posing a barrier for adoption. There is a critical need for evidence on DBT to inform its role in Australia, including evaluation of potentially more feasible models of implementation, and quantification of screening outcomes by breast density which has global relevance.

METHODS

This study is a prospective trial embedded in population-based Australian screening services (Maroondah BreastScreen, Eastern Health, Victoria) comparing hybrid screening comprising DBT (mediolateral oblique view) and digital mammography (cranio-caudal view) with standard mammography screening in a concurrent group attending another screening site. All eligible women aged ≥40 years attending the Maroondah service for routine screening will be enrolled (unless they do not provide verbal consent and opt-out of hybrid screening; are unable to provide consent; or where a 'pushback' image on hybrid DBT cannot be obtained). Each arm will enrol 20,000 women. The primary outcomes are cancer detection rate (per 1000 screens) and recall rate (percentage). Secondary outcomes include 'opt-out' rate; cohort characteristics; cancer characteristics; assessment outcomes; screen-reading time; and interval cancer rate at 24-month follow-up. Automated volumetric breast density will be measured to allow stratification of outcomes by mammographic density. Stratification by age and screening round will also be undertaken. An interim analysis will be undertaken after the first 5000 screens in the intervention group.

DISCUSSION

This is the first Australian prospective trial comparing hybrid DBT/mammography with standard mammography screening that is powered to show differences in cancer detection. Findings will inform future implementation of DBT in screening programs world-wide and provide evidence on whether DBT should be adopted in the broader BreastScreen program in Australia or in subgroups of screening participants.

TRIAL REGISTRATION

The trial is registered with the Australian New Zealand Clinical Trials Registry (ANZCTR, ACTRN12623001144606, https://www.anzctr.org.au/). Registration will be updated to reflect trial progress and protocol amendments.

Understanding general practitioners' prescribing choices to patients with chronic low back pain: a discrete choice experiment

BACKGROUND

Although NSAIDs are recommended as a first line analgesic treatment, opioids are very commonly prescribed to patients with low back pain (LBP) despite risks of harms.

AIM

This study aimed to determine factors contributing to general practitioners' (GPs') prescribing choices to patients with chronic LBP in a primary care setting.

METHOD

This discrete choice experiment (DCE) presented 210 GPs with hypothetical scenarios of a patient with chronic LBP. Participants chose their preferred treatment for each choice set, either the opioid, NSAID or neither. The scenarios varied by two patient attributes; non-specific LBP or LBP with referred leg pain (sciatica) and number of comorbidities. The three treatment attributes also varied, being: the type of opioid or NSAID, degree of pain reduction and number of adverse events. The significance of each attribute in influencing clinical decisions was the primary outcome and the degree to which GPs preferred the alternative based on the number of adverse events or the amount of pain reduction was the secondary outcome.

RESULTS

Overall, GPs preferred NSAIDs (45.2%, 95% CI 38.7-51.7%) over opioids (28.8%, 95% CI 23.0-34.7%), however there was no difference between the type of NSAID or opioid preferred. Additionally, the attributes of pain reduction and adverse events did not influence a GP's choice between NSAIDs or opioids for patients with chronic LBP.

CONCLUSION

GPs prefer prescribing NSAIDs over opioids for a patient with chronic low back pain regardless of patient factors of comorbidities or the presence of leg pain (i.e. sciatica).

Lung cancer screening program factors that influence psychosocial outcomes: A systematic review

OBJECTIVES

Lung cancer screening (LCS) programs are being designed and implemented globally. Early data suggests that the psychosocial impacts of LCS are influenced by program factors, but evidence synthesis is needed. This systematic review aimed to elucidate the impact of service-level factors on psychosocial outcomes to inform optimal LCS program design and future implementation.

METHODS

Four databases were searched from inception to July 2023. Inclusion criteria were full-text articles published in English that reported an association between any program factors and psychosocial outcomes experienced during LCS. Study quality was appraised, and findings were synthesised narratively.

RESULTS

Thirty-two articles were included; 29 studies were assessed at high or moderate risk of bias. Study designs were RCT (n = 3), pre-post (n = 6), cross-sectional (n = 12), mixed-methods (n = 1), and qualitative (n = 10) studies, and conducted primarily in the USA (n = 25). Findings suggested that targeted interventions can improve smoking-related or decisional psychosocial outcomes (e.g., smoking cessation interventions increase readiness/motivation to quit) but impacts of interventions on other psychological outcomes were varied. There was limited evidence reporting association between service delivery components and psychological outcomes, and results suggested moderation by individual aspects (e.g., expectation of results, baseline anxiety). Opportunities for discussion were key in reducing psychological harm.

CONCLUSIONS

Certain program factors are reportedly associated with psychosocial impacts of LCS, but study heterogeneity and quality necessitate more real-world studies. Future work should examine (a) implementation of targeted interventions and high-value discussion during LCS, and (b) optimal methods and timing of risk and result communication, to improve psychosocial outcomes while reducing time burden for clinicians.

Psychosocial outcomes and health service use after notifying women participating in population breast screening when they have dense breasts: a BreastScreen Queensland randomised controlled trial

BACKGROUND

Robust evidence regarding the benefits and harms of notifying Australian women when routine breast screening identifies that they have dense breasts is needed for informing future mammography population screening practice and policy.

OBJECTIVES

To assess the psychosocial and health services use effects of notifying women participating in population-based breast cancer screening that they have dense breasts; to examine whether the mode of communicating this information about its implications (print, online formats) influences these effects.

METHODS AND ANALYSIS

The study population comprises women aged 40 years or older who attend BreastScreen Queensland Sunshine Coast services for mammographic screening and are found to have dense breasts (BI-RADS density C or D). The randomised controlled trial includes three arms (952 women each): standard BreastScreen care (no notification of breast density; control arm); notification of dense breasts in screening results letter and print health literacy-sensitive information (intervention arm 1) or a link or QR code to online video-based health literacy-sensitive information (intervention arm 2). Baseline demographic data will be obtained from BreastScreen Queensland. Outcomes data will be collected in questionnaires at baseline and eight weeks, twelve months, and 27 months after breast screening. Primary outcomes will be psychological outcomes and health service use; secondary outcomes will be supplemental screening outcomes, cancer worry, perceived breast cancer risk, knowledge about breast density, future mammographic screening intentions, and acceptability of notification about dense breasts.

ETHICS APPROVAL

Gold Coast Hospital and Health Service Ethics Committee (HREC/2023/QGC/89770); Sunshine Coast Hospital and Health Service Research Governance and Development (SSA/2023/QSC/89770).

DISSEMINATION OF FINDINGS

Findings will be reported in peer-reviewed journals and at national and international conferences. They will also be reported to BreastScreen Queensland, BreastScreen Australia, Cancer Australia, and other bodies involved in cancer care and screening, including patient and support organisations.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12623000001695p (prospective: 9 January 2023).

Websites Selling Direct-to-Consumer Anti-Mullerian Hormone Tests

Importance

The recent provision of direct-to-consumer (DTC) Anti-Mullerian Hormone (AMH) testing in several countries has been contentious, particularly due to concerns about judicious testing and informed consent.

Objective

To describe and analyze information on websites that sell DTC AMH tests.

Design, Setting, and Participants

Qualitative study including content analysis of text information from websites in multiple countries that sell AMH tests DTC. The top 50 search results from 4 different internet search strings were captured and reviewed for eligibility. Data were extracted in March 2022 and analyzed from April 2022 to July 2023.

Main outcomes and measures

Themes and categories were derived from the website content using a conventional inductive approach, with a particular focus on information content, quality and accuracy, as well as the tone and language used.

Results

Twenty-seven websites across 7 different countries formed the sample for analysis. Information varied considerably across websites and was organized into 6 overarching categories: (1) whether a test description was included (25 websites [93%]); (2) statements about what the test can do, which included indicating ovarian reserve (26 websites [96%]) and indicating likelihood of conceiving (20 websites [74%]); (3) statements about the usefulness of the test result, which included enabling women to adjust their reproductive timeline (11 websites [41%]) and determining whether egg freezing was a viable option (8 websites [30%]); (4) blood collection method (ie, through a laboratory or an at-home sample); (5) promotion tactics, such as stating the convenience of testing (24 websites [89%]) and using language promoting empowerment and control (7 websites [26%]); and (6) statements about limitations of the test, which included polycystic ovary syndrome falsely inflating AMH levels (13 websites [48%]) and that it cannot accurately predict chances of conceiving (9 websites [33%]).

Conclusion and relevance

In this qualitative study including content analysis, most websites selling DTC AMH tests included false and misleading claims which might lead consumers to purchase an AMH test in the belief that it can reliably predict fertility potential and age of menopause. Depending on the test result, this may in turn lead to misplaced anxiety or reassurance about one's fertility and modifications to subsequent conception or contraceptive plans and behavior.

Women's views about current and future management of Ductal Carcinoma in Situ (DCIS): A mixed-methods study

Management of low-risk ductal carcinoma in situ (DCIS) is controversial, with clinical trials currently assessing the safety of active monitoring amidst concern about overtreatment. Little is known about general community views regarding DCIS and its management. We aimed to explore women's understanding and views about low-risk DCIS and current and potential future management options. This mixed-method study involved qualitative focus groups and brief quantitative questionnaires. Participants were screening-aged (50-74 years) women, with diverse socioeconomic backgrounds and no personal history of breast cancer/DCIS, recruited from across metropolitan Sydney, Australia. Sessions incorporated an informative presentation interspersed with group discussions which were audio-recorded, transcribed and analysed thematically. Fifty-six women took part in six age-stratified focus groups. Prior awareness of DCIS was limited, however women developed reasonable understanding of DCIS and the relevant issues. Overall, women expressed substantial support for active monitoring being offered as a management approach for low-risk DCIS, and many were interested in participating in a hypothetical clinical trial. Although some women expressed concern that current management may sometimes represent overtreatment, there were mixed views about personally accepting monitoring. Women noted a number of important questions and considerations that would factor into their decision making. Our findings about women's perceptions of active monitoring for DCIS are timely while results of ongoing clinical trials of monitoring are awaited, and may inform clinicians and investigators designing future, similar trials. Exploration of offering well-informed patients the choice of non-surgical management of low-risk DCIS, even outside a clinical trial setting, may be warranted.

Addressing Behavioral Barriers to COVID-19 Testing With Health Literacy-Sensitive eHealth Interventions: Results From 2 National Surveys and 2 Randomized Experiments

BACKGROUND

Polymerase chain reaction (PCR) testing for COVID-19 was crucial in Australia's prevention strategy in the first 2 years of the pandemic, including required testing for symptoms, contact with cases, travel, and certain professions. However, several months into the pandemic, half of Australians were still not getting tested for respiratory symptoms, and little was known about the drivers of and barriers to COVID-19 PCR testing as a novel behavior at that time.

OBJECTIVE

We aimed to identify and address COVID-19 testing barriers, and test the effectiveness of multiple eHealth interventions on knowledge for people with varying health literacy levels.

METHODS

The intervention was developed in 4 phases. Phase 1 was a national survey conducted in June 2020 (n=1369), in which testing barriers were coded using the capability-opportunity-motivation-behavior framework. Phase 2 was a national survey conducted in November 2020 (n=2034) to estimate the prevalence of testing barriers and health literacy disparities. Phase 3 was a randomized experiment testing health literacy-sensitive written information for a wide range of barriers between February and March 2021 (n=1314), in which participants chose their top 3 barriers to testing to view a tailored intervention. Phase 4 was a randomized experiment testing 2 audio-visual interventions addressing common testing barriers for people with lower health literacy in November 2021, targeting young adults as a key group endorsing misinformation (n=1527).

RESULTS

In phase 1, barriers were identified in all 3 categories: capability (eg, understanding which symptoms to test for), opportunity (eg, not being able to access a PCR test), and motivation (eg, not believing the symptoms are those of COVID-19). Phase 2 identified knowledge gaps for people with lower versus higher health literacy. Phase 3 found no differences between the intervention (health literacy-sensitive text for top 3 barriers) and control groups. Phase 4 showed that a fact-based animation or a TikTok-style video presenting the same facts in a humorous style increased knowledge about COVID-19 testing compared with government information. However, no differences were found for COVID-19 testing intentions.

CONCLUSIONS

This study identified a wide range of barriers to a novel testing behavior, PCR testing for COVID-19. These barriers were prevalent even in a health system where COVID-19 testing was free and widely available. We showed that key capability barriers, such as knowledge gaps, can be improved with simple videos targeting people with lower health literacy. Additional behavior change strategies are required to address motivational issues to support testing uptake. Future research will explore health literacy strategies in the current context of self-administered rapid antigen tests. The findings may inform planning for future COVID-19 variant outbreaks and new public health emergencies where novel testing behaviors are required.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry ACTRN12621000876897, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=382318 ; Australian New Zealand Clinical Trials Registry ACTRN12620001355965, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=380916&isReview=true.

Low-risk prostate lesions: An evidence review to inform discussion on losing the "cancer" label

BACKGROUND

Active surveillance (AS) mitigates harms from overtreatment of low-risk prostate lesions. Recalibration of diagnostic thresholds to redefine which prostate lesions are considered "cancer" and/or adopting alternative diagnostic labels could increase AS uptake and continuation.

METHODS

We searched PubMed and EMBASE to October 2021 for evidence on: (1) clinical outcomes of AS, (2) subclinical prostate cancer at autopsy, (3) reproducibility of histopathological diagnosis, and (4) diagnostic drift. Evidence is presented via narrative synthesis.

RESULTS

AS: one systematic review (13 studies) of men undergoing AS found that prostate cancer-specific mortality was 0%-6% at 15 years. There was eventual termination of AS and conversion to treatment in 45%-66% of men. Four additional cohort studies reported very low rates of metastasis (0%-2.1%) and prostate cancer-specific mortality (0%-0.1%) over follow-up to 15 years. Overall, AS was terminated without medical indication in 1%-9% of men. Subclinical reservoir: 1 systematic review (29 studies) estimated that the subclinical cancer prevalence was 5% at <30 years, and increased nonlinearly to 59% by >79 years. Four additional autopsy studies (mean age: 54-72 years) reported prevalences of 12%-43%. Reproducibility: 1 recent well-conducted study found high reproducibility for low-risk prostate cancer diagnosis, but this was more variable in 7 other studies. Diagnostic drift: 4 studies provided consistent evidence of diagnostic drift, with the most recent (published 2020) reporting that 66% of cases were upgraded and 3% were downgraded when using contemporary diagnostic criteria compared to original diagnoses (1985-1995).

CONCLUSIONS

Evidence collated may inform discussion of diagnostic changes for low-risk prostate lesions.

"I haven't had that information, even though I think I'm really well-informed about most things": a qualitative focus group study on Australian women's understanding and views of potentially modifiable risk factors for breast cancer

BACKGROUND

Building health literacy about potentially modifiable risk factors for breast cancer may help to empower women to make more informed decisions about their breast health; however there has been limited qualitative research on this topic. This study aimed to explore current knowledge, understanding and experience of potentially modifiable risk factors for breast cancer, and views on current and future communication strategies for this information and related interventions.

METHODS

Qualitative study using online focus groups via Zoom in October-November 2022. A diverse sample of women from the Australian community aged 40-74 years were recruited.

RESULTS

Fifty-one women from a range of socioeconomic backgrounds took part in nine focus groups. General knowledge of risk factors for breast cancer in the community is limited, particularly in relation to modifiable factors such as alcohol consumption and postmenopausal obesity, with many women describing feelings of 'shock' following this information. Women overwhelming believed that information on modifiable risk factors for breast cancer should be communicated more widely, however communication preferences for receiving this information varied. There was a strong preference amongst the women for a cascade of information which they believed may then help target greater number of women of all ages and backgrounds. Despite worry about long-term compliance, women also supported various lifestyle interventions which may help them and other women to reduce their overall risk.

CONCLUSIONS

Findings from this study highlight the need for more widespread community communication and education about risk factors for breast, in particular potentially modifiable risk factors such as alcohol consumption and postmenopausal obesity. As breast screening programs in Australia and globally begin to evaluate the potential for risk-related screening this will provide an additional context for primary prevention, hence planning of messaging and piloting of lifestyle-related prevention strategies in breast cancer is needed now. Gaining an understanding of women's preferences for communication and forms of interventions is vital to ensure their engagement.

Should low-risk DCIS lose the cancer label? An evidence review

BACKGROUND

Population mammographic screening for breast cancer has led to large increases in the diagnosis and treatment of ductal carcinoma in situ (DCIS). Active surveillance has been proposed as a management strategy for low-risk DCIS to mitigate against potential overdiagnosis and overtreatment. However, clinicians and patients remain reluctant to choose active surveillance, even within a trial setting. Re-calibration of the diagnostic threshold for low-risk DCIS and/or use of a label that does not include the word 'cancer' might encourage the uptake of active surveillance and other conservative treatment options. We aimed to identify and collate relevant epidemiological evidence to inform further discussion on these ideas.

METHODS

We searched PubMed and EMBASE databases for low-risk DCIS studies in four categories: (1) natural history; (2) subclinical cancer found at autopsy; (3) diagnostic reproducibility (two or more pathologist interpretations at a single time point); and (4) diagnostic drift (two or more pathologist interpretations at different time points). Where we identified a pre-existing systematic review, the search was restricted to studies published after the inclusion period of the review. Two authors screened records, extracted data, and performed risk of bias assessment. We undertook a narrative synthesis of the included evidence within each category.

RESULTS

Natural History (n = 11): one systematic review and nine primary studies were included, but only five provided evidence on the prognosis of women with low-risk DCIS. These studies reported that women with low-risk DCIS had comparable outcomes whether or not they had surgery. The risk of invasive breast cancer in patients with low-risk DCIS ranged from 6.5% (7.5 years) to 10.8% (10 years). The risk of dying from breast cancer in patients with low-risk DCIS ranged from 1.2 to 2.2% (10 years). Subclinical cancer at autopsy (n = 1): one systematic review of 13 studies estimated the mean prevalence of subclinical in situ breast cancer to be 8.9%. Diagnostic reproducibility (n = 13): two systematic reviews and 11 primary studies found at most moderate agreement in differentiating low-grade DCIS from other diagnoses. Diagnostic drift: no studies found.

CONCLUSION

Epidemiological evidence supports consideration of relabelling and/or recalibrating diagnostic thresholds for low-risk DCIS. Such diagnostic changes would need agreement on the definition of low-risk DCIS and improved diagnostic reproducibility.

Australian Women's Responses to Breast Density Information: A Content Analysis

Breast density (BD) is an independent risk factor for breast cancer and reduces mammographic sensitivity. This study explored women's responses and intentions if notified that they had dense breasts.

METHODS

Content analysis was used to assess responses from a written questionnaire undertaken in conjunction with focus groups on BD involving 78 Australian women aged 40-74.

RESULTS

Half the women reported that they would feel a little anxious if notified they had dense breasts, while 29.5% would not feel anxious. The most common theme (29.5%) related to anxiety was the psychosocial impact of the possibility of developing cancer, and women believed that being better informed could help with anxiety (26.9%). When asked what they would do if notified of having dense breasts, the most common response was to consult their doctor for information/advice (38.5%), followed by considering supplemental screening (23%). Consequently, when asked directly, 65.4% were interested in undergoing supplemental screening, while others (10.3%) said they "wouldn't worry about it too much".

DISCUSSION

These findings have important implications for health systems with population-based breast screening programs that are currently considering widespread BD notification in terms of the impact on women, health services and primary care.

A systematic review of the impact of the COVID-19 pandemic on breast cancer screening and diagnosis

BACKGROUND

Breast cancer care has been affected by the COVID-19 pandemic. This systematic review aims to describe the observed pandemic-related changes in clinical and health services outcomes for breast screening and diagnosis.

METHODS

Seven databases (January 2020-March 2021) were searched to identify studies of breast cancer screening or diagnosis that reported observed outcomes before and related to the pandemic. Findings were presented using a descriptive and narrative approach.

RESULTS

Seventy-four studies were included in this systematic review; all compared periods before and after (or fluctuations during) the pandemic. None were assessed as being at low risk of bias. A reduction in screening volumes during the pandemic was found with over half of studies reporting reductions of ≥49%. A majority (66%) of studies reported reductions of ≥25% in the number of breast cancer diagnoses, and there was a higher proportion of symptomatic than screen-detected cancers. The distribution of cancer stage at diagnosis during the pandemic showed lower proportions of early-stage (stage 0-1/I-II, or Tis and T1) and higher proportions of relatively more advanced cases than that in the pre-pandemic period, however population rates were generally not reported.

CONCLUSIONS

Evidence of substantial reductions in screening volume and number of diagnosed breast cancers, and higher proportions of advanced stage cancer at diagnosis were found during the pandemic. However, these findings reflect short term outcomes, and higher-quality research examining the long-term impact of the pandemic is needed.

A systematic assessment of online international breast density information

Background

Breast density has become a topic of international discussion due to its associated risk of breast cancer. As online is often a primary source of women's health information it is therefore essential that breast density information it is understandable, accurate and reflects the best available evidence. This study aimed to systematically assess online international breast density information including recommendations to women.

Methods

Searches were conducted from five different English-speaking country-specific Google locations. Relevant breast density information was extracted from the identified websites. Readability was assessed using the SHeLL Editor, and understandability and actionability using the Patient Education Materials Assessment Tool (PEMAT). A content analysis of specific recommendations to women was also conducted.

Results

Forty-two eligible websites were identified and systematically assessed. The included informational content varied across websites. The average grade reading level across all websites was 12.4 (range 8.9–15.4). The mean understandability was 69.9% and the mean actionability was 40.1%, with 18/42 and 39/42 websites respectively scoring lower than adequate (70%). Thirty-six (85.7%) of the websites had breast density-related recommendation to women, with ‘talk to your doctor’ (n = 33, 78.6%) the most common.

Conclusions

Online information about breast density varies widely and is not generally presented in a way that women can easily understand and act on, therefore greatly reducing the ability for informed decision-making. International organisations and groups disseminating breast density information need to ensure that women are presented with health literacy-sensitive and balanced information, and be aware of the impact that recommendations may have on practice.

•

First study to systematically assess online international breast density information.

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Information across the websites varies widely.

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Readability, understandability and actionability are low and poor.

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The most common recommendation to women is to ‘talk to your doctor’.

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More health literacy-sensitive online information about breast density is needed internationally.

Factors associated with women's supplemental screening intentions following dense breast notification in an online randomised experimental study

Controversy surrounding recommendations for supplemental screening (ultrasound and magnetic resonance screening) in women with dense breasts exists, as the long-term benefits from these additional modalities may not outweigh the harms. This study aimed to examine factors associated with supplemental screening intentions following a hypothetical breast density notification in a population of women who have not been routinely notified. Australian women of breast screening age participated in an online randomised experimental study where they were presented with one of two breast density notifications (with or without health literacy-sensitive information) and asked their screening intentions. After adjusting for covariates in multivariable analyses, women in both groups (n = 940) who indicated higher levels of breast cancer worry, had private health insurance, had a family history of breast cancer, and had a greater number of times previously attending mammography screening had higher intentions for supplemental screening. Understanding women's supplemental screening intentions following notification of dense breasts has important implications for health systems with breast screening considering the impacts of widespread notification. Personal, clinical and psychological factors should be considered when discussing both the benefits and harms of supplemental screening with women with dense breasts.

Australian General Practitioners' Current Knowledge, Understanding, and Feelings Regarding Breast Density Information and Notification: A Cross-Sectional Study

BACKGROUND

There is a lack of evidence around Australian general practitioners' (GPs) views of issues surrounding breast density. The current study aimed to quantitatively assess GPs' current knowledge, understanding, and feelings around breast density information and notification.

METHODS

This study involved a cross-sectional survey using an online platform to collect quantitative data from Australian GPs. Survey data were analysed with descriptive statistics.

RESULTS

A total 60 responses from GPs were analysed. Most (n = 58; 97%) had heard or read about breast density and nearly 90% (n = 52; 87%) have had discussions about breast density with patients. Three-quarters (n = 45; 75%) were supportive of making breast density notification mandatory for patients with dense tissue and a similar proportion (n = 45/58; 78%) felt they need or want more education on breast density.

CONCLUSIONS

There is strong support for notifying patients of breast density, and interest in further education and training among the surveyed GPs. As GPs play a central role in cancer prevention and control, their involvement in discussions related to breast density notification, evaluation and appraisal of evidence, development of communication strategies, and participation in ongoing research on the topic will be indispensable.

Factors That Inform Individual Decision Making Between Active Surveillance, Hemithyroidectomy and Total Thyroidectomy for Low-Risk Thyroid Cancer: A Scoping Review

Background: Due to the excellent prognosis and relatively high incidence of small low-risk thyroid cancers, more conservative management strategies such as active surveillance (AS) or hemithyroidectomy (HT) may be preferable to total thyroidectomy (TT) for patients seeking to balance long-term survival rates with the potential adverse effects of overtreatment. The aim of this review was to synthesize key factors or variables that inform patient decision making about treatment for low-risk thyroid cancer, from current primary investigations that presented participants with information facilitating this choice. Methods: Studies were identified from the Medline, Cochrane, and Embase databases up until March 2022. Study characteristics were extracted into a pre-piloted form. Factors were hypothesized to include treatment-related risks and possible outcomes and identified from a review of studies with consensus by discussion. Results: The search identified 444 unique studies: 397 were excluded on review of abstract and title with 47 studies undergoing a full text review and 6 studies identified to be eligible. Four were cross-sectional: one a prospective cohort study and one a mixed-methods study with both a prospective observational and qualitative component. The decisions addressed included: the choice between AS versus surgery (HT and/or TT) and HT versus TT and enrolled participants ranging from healthy volunteers to thyroid cancer patients. Treatment choice was the primary outcome in five studies. Across the studies, participants who were given the option of AS or surgery predominately chose the more conservative pathway, with a range of 70-84%. The major factors represented by information provision in the studies were risk of cancer recurrence or spread, need for hormone replacement therapy, and voice change. Conclusions: A framework of key factors informing patient treatment choice may be derived from current studies involving information provision for low-risk thyroid cancer management. Further research evaluating the efficacy and optimal timing for decision support interventions would help inform the design and clinical use of these tools to promote shared decision making.

Interventions to improve media coverage of medical research: a codesigned feasibility and acceptability study with Australian journalists

OBJECTIVES

Although the media can influence public perceptions and utilisation of healthcare, journalists generally receive no routine training in interpreting and reporting on medical research. Given growing evidence about the problems of medical overuse, the need for quality media reporting has become a greater priority. This study aimed to codesign and assess the feasibility of a multicomponent training intervention for journalists in Australia.

DESIGN

A small pragmatic feasibility study using a pre- and postdesign.

SETTING

90 min online workshop.

PARTICIPANTS

Eight journalists currently working in Australia, recruited through the study's journalist advisor and existing contacts of the researchers.

INTERVENTION

The training intervention covered a range of topics, including study designs, conflicts of interest, misleading medical statistics, population screening and overdiagnosis. The intervention also provided tools to help journalists with reporting, including a Tip Sheet and list of expert contacts in health and medicine. Preworkshop and postworkshop questionnaires were administered via Qualtrics.

MEASURES

Acceptability and feasibility of the intervention, and journalists' knowledge of overdiagnosis and common issues with health stories. Quantitative results were analysed descriptively using SPSS. Qualitative data were thematically analysed.

RESULTS

All participants completed preworkshop and postworkshop questionnaires, and 6 completed the 6-week follow-up (75% retention). Feasibility findings suggest the intervention is acceptable and relevant to journalists, with participants indicating the workshop increased confidence with reporting on medical research. We observed increases in knowledge preworkshop to postworkshop for all knowledge measures on overdiagnosis and common issues with media coverage of medicine. Analysis of free-text responses identified several areas for improvement, such as including more examples to aid understanding of the counterintuitive topic of overdiagnosis and more time for discussion.

CONCLUSIONS

Piloting suggested the multicomponent training intervention is acceptable to journalists and provided important feedback and insights to inform a future trial of the intervention's impact on media coverage of medicine.

Effects of awareness of breast cancer overdiagnosis among women with screen-detected or incidentally found breast cancer: a qualitative interview study

OBJECTIVES

To explore experiences of women who identified themselves as having a possible breast cancer overdiagnosis.

DESIGN

Qualitative interview study using key components of a grounded theory analysis.

SETTING

International interviews with women diagnosed with breast cancer and aware of the concept of overdiagnosis.

PARTICIPANTS

Twelve women aged 48-77 years from the UK (6), USA (4), Canada (1) and Australia (1) who had breast cancer (ductal carcinoma in situ n=9, (invasive) breast cancer n=3) diagnosed between 2004 and 2019, and who were aware of the possibility of overdiagnosis. Participants were recruited via online blogs and professional clinical networks.

RESULTS

Most women (10/12) became aware of overdiagnosis after their own diagnosis. All were concerned about the possibility of overdiagnosis or overtreatment or both. Finding out about overdiagnosis/overtreatment had negative psychosocial impacts on women's sense of self, quality of interactions with medical professionals, and for some, had triggered deep remorse about past decisions and actions. Many were uncomfortable with being treated as a cancer patient when they did not feel 'diseased'. For most, the recommended treatments seemed excessive compared with the diagnosis given. Most found that their initial clinical teams were not forthcoming about the possibility of overdiagnosis and overtreatment, and many found it difficult to deal with their set management protocols.

CONCLUSION

The experiences of this small and unusual group of women provide rare insight into the profound negative impact of finding out about overdiagnosis after breast cancer diagnosis. Previous studies have found that women valued information about overdiagnosis before screening and this knowledge did not reduce subsequent screening uptake. Policymakers and clinicians should recognise the diversity of women's perspectives and ensure that women are adequately informed of the possibility of overdiagnosis before screening.

Australian Women's Intentions and Psychological Outcomes Related to Breast Density Notification and Information: A Randomized Clinical Trial

IMPORTANCE

Whether the benefits of notifying women about breast density outweigh the potential harms to inform current and future mammogram screening practice remains unknown.

OBJECTIVE

To assess the effect of mammographic breast density notification and information provision on women's intention to seek supplemental screening and psychological outcomes.

DESIGN, SETTING, AND PARTICIPANTS

A 3-arm online randomized clinical trial was conducted from August 10 to 31, 2021. Data analysis was conducted from September 1 to October 20, 2021. Participants included Australian residents identifying as female, aged between 40 and 74 years, with no history of breast cancer who were residing in jurisdictions without existing breast density notification with screening mammograms.

INTERVENTIONS

Women were randomized to receive 1 of the following hypothetical breast screening test result letters: screening mammogram result letter without breast density messaging (control), screening mammogram result letter with breast density messaging and an existing density information letter taken from a screening service in Australia (intervention 1), and screening mammogram result letter with breast density messaging and a health literacy-sensitive version of the letter adapted for people with lower health literacy (intervention 2).

MAIN OUTCOMES AND MEASURES

Primary outcomes were intention to seek supplemental screening; feeling anxious (uneasy, worried, or nervous), informed, or confused; and having breast cancer worry.

RESULTS

A total of 1420 Australian women were randomized and included in the final analysis. The largest group consisted of 603 women aged 60 to 74 years (42.5%). Compared with the control cohort (n = 480), women who received density notification via intervention 1 (n = 470) and intervention 2 (n = 470) reported a significantly higher intention to seek supplemental screening (0.8% vs 15.6% and 14.2%; P < .001) and feeling anxious (14.2% vs 49.4% and 48.5%; P < .001), confusion (7.8% vs 24.0% and 23.6%; P < .001), and worry about breast cancer (quite/very worried: 6.9% vs 17.2% and 15.5%; P < .001). There were no statistically significant differences in these outcomes between the 2 intervention groups.

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, breast density notification and information integrated with screening mammogram results increased women's intention to seek supplemental screening and made women feel anxious, confused, or worried about breast cancer. These findings have relevance and implications for mammogram screening services and policy makers considering whether and, if so, how best to implement widespread notification of breast density as part of mammography screening.

TRIAL REGISTRATION

ACTRN12621000253808.

Perceived public health threat a key factor for willingness to get the COVID-19 vaccine in Australia

BACKGROUND

Vaccination rollout against COVID-19 is underway across multiple countries worldwide. Although the vaccine is free, rollout might still be compromised by hesitancy or concerns about COVID-19 vaccines.

METHODS

We conducted two online surveys of Australian adults in April (during national lockdown; convenience cross-sectional sample) and November (very few cases of COVID-19; nationally representative sample) 2020, prior to vaccine rollout. We asked about intentions to have a potential COVID-19 vaccine (If a COVID-19 vaccine becomes available, I will get it) and free-text responses (November only).

RESULTS

After adjustment for differences in sample demographics, the estimated proportion agreeing to a COVID-19 vaccine if it became available in April (n = 1146) was 76.3%. In November (n = 1941) this was estimated at 71.5% of the sample; additional analyses identified that the variation was driven by differences in perceived public health threat between April and November. Across both surveys, female gender, being younger, having inadequate health literacy and lower education were associated with reluctance to be vaccinated against COVID-19. Lower perceived susceptibility to COVID-19, belief that data on the efficacy of vaccines is 'largely made up', having lower confidence in government, and lower perception of COVID-19 as a public health threat, were also associated with reluctance to be vaccinated against COVID-19. The top three reasons for agreeing to vaccinate (November only) were to protect myself and others, moral responsibility, and having no reason not to get it. For those who were indifferent or disagreeing to vaccinate, safety concerns were the top reason, followed by indecision and lack of trust in the vaccine respectively.

CONCLUSIONS

These findings highlight some factors related to willingness to accept a COVID-19 vaccine prior to one being available in Australia. Now that the vaccine is being offered, this study identifies key issues that can inform public health messaging to address vaccine hesitancy.

Positive outcomes associated with the COVID-19 pandemic in Australia

ISSUE ADDRESSED

To investigate whether Australians have experienced any positive effects during the COVID-19 pandemic.

METHODS

National online longitudinal survey. As part of a June 2020 survey, participants (n = 1370) were asked 'In your life, have you experienced any positive effects from the COVID-19 pandemic' (yes/no) and also completed the World Health Organisation-Five well-being index. Differences were explored by demographic variables. Free-text responses were thematically coded.

RESULTS

Nine hundred sixty participants (70%) reported experiencing at least one positive effect during the COVID-19 pandemic. Living with others (P = .045) and employment situation (P < .001) at baseline (April) were associated with experiencing positive effects. Individuals working for pay from home were more likely to experience positive effects compared to those who were not working for pay (aOR = 0.45, 95% CI: 0.32, 0.63, P < .001) or who were working for pay outside the home (aOR = 0.40, 95% CI: 0.28, 0.58, P < .001). 54.2% of participants reported a sufficient level of well-being, 23.2% low well-being and a further 22.6% very low well-being. Of those experiencing positive effects, 945/960 (98%) provided an explanation. The three most common themes were 'Family time' (33%), 'Work flexibility' (29%) and 'Calmer life' (19%).

CONCLUSIONS

A large proportion of participants reported positive effects resulting from changes to daily life due to the COVID-19 pandemic in Australia.

SO WHAT

The needs of people living alone, and of those having to work outside the home or who are unemployed, should be considered by health policymakers and employers in future pandemic preparedness efforts.

"It's about our bodies… we have the right to know this stuff": A qualitative focus group study on Australian women's perspectives on breast density

OBJECTIVE

This study aimed to explore Australian women's current knowledge, perspectives and attitudes about breast density (BD); and information needs to inform effective evidence-based communication strategies.

METHODS

Fourteen online focus group sessions with a total of 78 women in New South Wales and Queensland, Australia aged 40-74 years without a personal diagnosis of breast cancer were conducted. Audio-recorded data was transcribed and analysed thematically.

RESULTS

Women had a very limited knowledge of BD. Overall, women expressed a preference for more frequent mammograms and/or supplemental screening should they be told they had dense breasts, despite being presented with information on potential downsides of additional testing. The majority of women were supportive of the notion of BD notification, often suggesting they had a 'right to know' and they would prefer to be educated and informed about it.

CONCLUSION

The potential of being informed and notified of BD is found to be of interest and importance to Australian women of breast screening age despite lacking current knowledge.

PRACTICE IMPLICATIONS

This study highlights that policy makers and screening services need to consider how to weigh up these views and preferences of women with current evidence surrounding BD in deciding about implementing population-based BD notification.

Rethinking Low-Risk Papillary Thyroid Cancers < 1cm (Papillary Microcarcinomas): An Evidence Review for Recalibrating Diagnostic Thresholds and/or Alternative Labels

Background: Recalibrating diagnostic thresholds or using alternative labels may mitigate overdiagnosis and overtreatment of papillary microcarcinoma (mPTC). We aimed at identifying and collating relevant epidemiological evidence on mPTC, to assess the case for recalibration and/or new labels. Methods: We searched EMBASE and PubMed databases from inception to December 2020 for natural history, autopsy, diagnostic drift, and diagnostic reproducibility studies. Where a relevant systematic review was pre-identified, only new articles were additionally included. Non-English articles were excluded. One author screened titles and abstracts. Two authors screened full text articles, performed quality assessments, and extracted data. We undertook narrative synthesis of included evidence (pooled estimates from systematic reviews and single estimates from primary studies). Results: One systematic review of patients undergoing active surveillance found that after 5 years of follow-up, 5.3% (95% confidence interval [CI 4.4-6.4%]) of the mPTC lesions had increased in size by ≥3 mm, and 1.6% [CI 1.1-2.4%] of patients had lymph node metastases. Among 7 new primary studies (including 3 updates on 2 studies included in the systematic review), 1-5% of patients undergoing active surveillance had lymph node metastases after a median follow-up of 1-10 years. One systematic review found that subclinical thyroid cancer incidentally discovered at autopsy is relatively common, with a pooled prevalence of 11.2% [CI 6.7-16.1%] among studies that examined the whole thyroid. Four diagnostic drift studies evaluated the new classification of non-invasive follicular thyroid neoplasm with papillary-like nuclear features (NIFTP). Three studies of cases previously diagnosed as papillary thyroid cancer found 1.3-2.3% were reclassified as NIFTP (reclassifications were from follicular variation of papillary thyroid cancer [FVPTC]). One study of 48 cases previously diagnosed as mPTC found that 23.5% were reclassified as NIFTP. Thirteen reproducibility studies of papillary thyroid lesions found substantial variation in the histopathological diagnosis of thyroid lesions, including FVPTC and NIFTP classifications (no study evaluated mPTC). Conclusions: This review supports consideration of recalibrating diagnostic thresholds and/or alternative labels for low-risk mPTC.

The Impact of Breast Density Information or Notification on Women's Cognitive, Psychological, and Behavioral Outcomes: A Systematic Review

BACKGROUND

Breast density (BD) is an independent risk factor for breast cancer and reduces the sensitivity of mammography. This systematic review aims to synthesize evidence from existing studies to understand the impact of BD information and/or notification on women's cognitive, psychological, and behavioral outcomes.

METHODS

Studies were identified via relevant database searches up to March 2020. Two authors evaluated the eligibility of studies with verification from the study team, extracted and crosschecked data, and assessed the risk of bias.

RESULTS

Of the 1134 titles identified, 29 studies were included. Twenty-three studies were quantitative, including only 1 randomized controlled trial of women receiving BD information, and 6 were qualitative. Twenty-seven studies were conducted in the United States, with 19 conducted post-BD legislation. The overall results in terms of BD awareness, knowledge, attitudes, perceptions, and intentions were heterogeneous across included studies, with the strongest consistency demonstrated regarding the importance of communication with and involvement of health-care professionals. Together, the studies did, however, highlight that there is still limited awareness of BD in the community, especially in more socioeconomic disadvantaged communities, and limited knowledge about what BD means and the implications for women. Importantly, BD information in the context of overall breast cancer risk has not yet been studied.

CONCLUSIONS

There are important gaps in the understanding of the impact of BD information or notification on women and how best to communicate BD information to women. More high-quality evidence to inform both current and future practice related to BD is still needed.

COVID-19 challenges faced by general practitioners in Australia: a survey study conducted in March 2021

Limited studies at the beginning of the COVID-19 pandemic found GPs have been negatively affected by increased workload, reduced income and major concerns about staff and patient safety. This study aimed to investigate the challenges of COVID-19 in general practice 1 year since it was declared a pandemic. A national cross-sectional online survey was conducted in March 2021 of a convenience sample of 295 Australian GPs attending an online educational webcast. Twenty-five multipart and free-text questions collected information regarding GPs' main COVID-19-related issues and concerns, including COVID-19 vaccines, useful sources of information, information needs and their perceived role as GPs in COVID-19 management. Descriptive statistics were calculated for all quantitative variables. Content analysis was used to analyse text data from open-ended questions. Of the 596 eligible attendees of the online educational webcast, 295 completed the survey (49.5% response rate). One year since COVID-19 was declared a pandemic, GPs still have concerns regarding patients ignoring prescreening and presenting with flu-like symptoms, the safety of their colleagues and family and catching COVID-19 themselves, as well as concerns about the effect of the pandemic on their patients and patients delaying essential care for non-COVID-19 conditions. More education and resources about vaccines was identified as the top information need, which will assist with what GPs' perceived to be their key roles in managing the COVID-19 pandemic, namely educating the public, correcting misunderstandings and providing the COVID-19 vaccine. These findings highlight gaps in communication and information, particularly regarding COVID-19 vaccines. GPs need high-quality information and resources to support them in undertaking complex risk communication with their patients.

General practitioners' (GPs) understanding and views on breast density in Australia: a qualitative interview study

OBJECTIVES

To understand general practitioners' (GPs') awareness and knowledge of mammographic breast density (BD) and their perspectives around information and potential notification of BD for women.

DESIGN

Qualitative study using semistructured telephone interviews. Interviews were audiorecorded, transcribed and analysed using framework analysis.

SETTING

Australia.

PARTICIPANTS

Australian GPs (n=30).

RESULTS

GPs had limited knowledge of BD and little experience discussing BD with women. There were mixed views on notification of BD with some GPs believing this information would help informed decision making about breast health and that women have the right to know any information about their bodies. While others were concerned about causing unnecessary anxiety and were worried about the uncertainty about what to advise women to do with this information, particularly in relation to supplemental breast screening. The need for an equitable system where all women are either notified or not, and also provided with publicly funded supplemental screening was raised by GPs. Overall, there was high interest in education, training and support around the topic of BD.

CONCLUSIONS

Australian GPs require education, support and evidence-based guidelines to have discussions with women with dense breasts and help manage their risk, especially if widespread notification is to be introduced in population-based screening programmes.

Anti-Mullerian hormone (AMH) test information on Australian and New Zealand fertility clinic websites: a content analysis

OBJECTIVES

The anti-Mullerian hormone (AMH) test has been promoted as a way to inform women about their future fertility. However, data consistently show the test is a poor predictor of natural fertility potential for an individual woman. As fertility centre websites are often a primary source of information for reproductive information, it is essential the information provided is accurate and reflects the available evidence. We aimed to systematically record and categorise information about the AMH test found on Australian and New Zealand fertility clinic websites.

DESIGN

Content analysis of online written information about the AMH test on fertility clinic websites.

SETTING

Accredited Australian and New Zealand fertility clinic websites.

METHODS

Data were extracted between April and June 2020. Any webpage that mentioned the AMH test, including blogs specifically about the AMH test posted since 2015, was analysed and the content categorised.

RESULTS

Of the 39 active accredited fertility clinics' websites, 25 included information about the AMH test. The amount of information varied widely, and embodied four overarching categories; (1) the utility of the AMH test, (2) who the test is suitable for, (3) possible actions in response to the test and (4) caveats and limitations of the test. Eight specific statements about the utility of the test were identified, many of which are not evidence-based. While some websites were transparent regarding the test's limitations, others mentioned no caveats or included persuasive statements actively promoting the test as empowering for a range of women in different circumstances.

CONCLUSIONS

Several websites had statements about the utility of the AMH test that are not supported by the evidence. This highlights the need for higher standards for information provided on fertility clinic websites to prevent women being misled to believe the test can reliably predict their fertility.

Terminology Change for Small Low-Risk Papillary Thyroid Cancer As a Response to Overtreatment: Results from Three Australian Community Juries

Background: The majority of small papillary thyroid cancers (sPTCs) are treated surgically, rather than by active surveillance. Patient and clinician preference for surgery may be partially driven by the use of cancer terminology. Some experts propose that changing terminology would better communicate the indolent nature of sPTCs and improve uptake of active surveillance. Others argue that terminology that includes "cancer" correctly reflects the biological nature of these tumors. The views of informed lay publics can provide value-based perspectives on complex issues and guide policy discussions. Methods: We recruited 40 people for three community juries, held in Sydney, Wodonga, and Cairns, Australia. Participants were of diverse backgrounds and ages, recruited through random digit dialing and a topic-blinded social media strategy. Juries were informed about thyroid cancer, overdiagnosis, and overtreatment, and heard arguments for and against terminology change before deliberation. The deliberative process in Jury 1 led to a refinement of jury charge, the updated version that was then used in Juries 2 and 3. Results: Jury 1 favored no terminology change, and Juries 2 and 3 were divided on the topic. Key reasons for opposing terminology change included a strong desire to retain terminology that aligns with the pathological definition of cancer, and to avoid even a minimal risk of harm that could arise if patients became complacent in follow-up. Key reasons to support terminology change included a desire to reduce psychological distress, stigma, and discrimination associated with a cancer diagnosis, and an argument that terminology change may be a more effective trigger for health system reform compared with other options. The juries unanimously recommended community education and health system reforms to reduce harms of overtreatment, and expressed an expectation that clinicians and researchers reach agreement on clinical guidelines to promote better uptake of active surveillance. Conclusions: The conceptual tension between a pathological and an outcome-based understanding of cancer was apparent in deliberation. This highlights an ongoing challenge for those advocating changing disease terminology. Regardless of action on terminology, jurors shared a strong expectation that practical changes would be made to respond to the harms of overtreatment.

Contextualising COVID-19 prevention behaviour over time in Australia: Patterns and long-term predictors from April to July 2020 in an online social media sample

BACKGROUND

In Australia in March 2020 a national public health directive required that non-essential workers stay at home, except for essential activities. These restrictions began easing in May 2020 as community transmission slowed.

OBJECTIVES

This study investigated changes in COVID prevention behaviours from April-July 2020, and psychosocial predictors of these behaviours.

METHODS

An Australia-wide (national) survey was conducted in April, with monthly follow-up over four months. Participants who were adults (18+ years), currently residing in Australia and who could read and understand English were eligible. Recruitment was via online social media. Analysis sample included those who provided responses to the baseline survey (April) and at least one subsequent follow-up survey (N = 1834 out of a possible 3216 who completed the April survey). 71.7% of the sample was female (n = 1,322). Principal components analysis (PCA) combined self-reported adherence across seven prevention behaviours. PCA identified two behaviour types: 'distancing' (e.g. staying 1.5m away) and 'hygiene' (e.g. washing hands), explaining 28.3% and 24.2% of variance, respectively. Distancing and hygiene behaviours were analysed individually using multivariable regression models.

RESULTS

On average, participants agreed with statements of adherence for all behaviours (means all above 4 out of 7). Distancing behaviours declined each month (p's < .001), whereas hygiene behaviours remained relatively stable. For distancing, stronger perceptions of societal risk, self-efficacy to maintain distancing, and greater perceived social obligation at baseline were associated with adherence in June and July (p's<0.05). For hygiene, the only significant correlate of adherence in June and July was belief that one's actions could prevent infection of family members (p < .001).

CONCLUSION

High adherence to COVID prevention behaviours were reported in this social media sample; however, distancing behaviours tended to decrease over time. Belief in social responsibility may be an important aspect to consider in encouraging distancing behaviours. These findings have implications for managing a shift from government-imposed restrictions to individual responsibility.

Journalists' views on media coverage of medical tests and overdiagnosis: a qualitative study

OBJECTIVE

Promotional media coverage of early detection tests is an important driver of overdiagnosis. Following research evidence that global media coverage presents the benefits of testing healthy people far more frequently than harms, and gives little coverage to overdiagnosis, we sought to examine journalists' views on media reporting of tests, overdiagnosis, and strategies to improve critical reporting on tests.

DESIGN

Qualitative study using semistructured telephone interviews. Interviews were conducted between February and March 2020 and were audiorecorded and transcribed verbatim. Framework thematic analysis was used to analyse the data.

PARTICIPANTS AND SETTING

Twenty-two journalists (mainly specialising in health reporting, average 14.5 years' experience) based in Australia.

RESULTS

This sample of journalists acknowledged the potential harms of medical tests but felt that knowledge of harms was low among journalists and the public at large. Most were aware of the term overdiagnosis, but commonly felt that it is challenging to both understand and communicate in light of strong beliefs in the benefits of early detection. Journalists felt that newsworthiness in the form of major public health impact was the key ingredient for stories about medical tests. The journalists acknowledged that factors, like the press release and 'click bait culture' in particular, can influence the framing of coverage about tests. Lack of knowledge and training, as well as time pressures, were perceived to be the main barriers to critical reporting on tests. Journalists felt that training and better access to information about potential harms would enable more critical reporting.

CONCLUSIONS

Effectively communicating overdiagnosis is a challenge in light of common beliefs about the benefits of testing and the culture of current journalism practices. Providing journalists with training, support and better access to information about potential harms of tests could aid critical reporting of tests.

Positive outcomes associated with the COVID-19 pandemic in Australia

ISSUE ADDRESSED

To investigate whether Australians have experienced any positive effects during the COVID-19 pandemic.

METHODS

National online longitudinal survey. As part of a June 2020 survey, participants (n = 1370) were asked 'In your life, have you experienced any positive effects from the COVID-19 pandemic' (yes/no) and also completed the World Health Organisation-Five well-being index. Differences were explored by demographic variables. Free-text responses were thematically coded.

RESULTS

Nine hundred sixty participants (70%) reported experiencing at least one positive effect during the COVID-19 pandemic. Living with others (P = .045) and employment situation (P < .001) at baseline (April) were associated with experiencing positive effects. Individuals working for pay from home were more likely to experience positive effects compared to those who were not working for pay (aOR = 0.45, 95% CI: 0.32, 0.63, P < .001) or who were working for pay outside the home (aOR = 0.40, 95% CI: 0.28, 0.58, P < .001). 54.2% of participants reported a sufficient level of well-being, 23.2% low well-being and a further 22.6% very low well-being. Of those experiencing positive effects, 945/960 (98%) provided an explanation. The three most common themes were 'Family time' (33%), 'Work flexibility' (29%) and 'Calmer life' (19%).

CONCLUSIONS

A large proportion of participants reported positive effects resulting from changes to daily life due to the COVID-19 pandemic in Australia.

SO WHAT

The needs of people living alone, and of those having to work outside the home or who are unemployed, should be considered by health policymakers and employers in future pandemic preparedness efforts.

The impact of mandatory mammographic breast density notification on supplemental screening practice in the United States: a systematic review

PURPOSE

Dense breast tissue is an independent risk factor for breast cancer and lowers the sensitivity of screening mammography. Supplemental screening with ultrasound or MRI improves breast cancer detection rate but has potential harms. Breast density notification (BDN) legislation has been introduced in the United States (US) and its impact on supplemental screening practice is unclear. This study systematically reviewed current evidence to explore the impact of BDN on supplemental screening practice in the US.

METHODS

Medline, PubMed, Embase, Cochrane and the Cinhal Library databases were searched (2009-August 2020). Studies were assessed for eligibility, data were extracted and summarised, and study quality was evaluated.

RESULTS

Evidence from the included studies (n = 14) predominantly showed that BDN legislation increased the overall utilisation of supplemental screening by 0.5-143%. This effect was amplified if the notification included a follow-up telephone call informing women about additional screening benefits, and if the state's law mandated insurance cover for supplemental screening. Likelihood of supplemental screening was also influenced by history of breast biopsy and family history of breast cancer, race, age, socioeconomic status, density category, and physician's specialty and region. Some studies reported increases in biopsy rate (up to 4%) and cancer detection rate (up to 11%) after implementation of BDN legislation.

CONCLUSION

BDN leads to increased use of supplemental screening. This has implications for women and the health system. These findings can help inform current and future screening programs, where breast density notification is currently implemented or being considered.

Breast Density Notification: A Systematic Review of the Impact on Primary Care Practitioners

Background: In the last decade, there has been an unprecedented amount of advocacy and attention surrounding the issue of breast density (BD) in relation to mammography screening. It is largely unknown what impact notifying women of their BD has had on clinical practice for PCPs. This systematic review aimed to synthesize evidence from existing studies to understand the impact of BD notification on primary care practitioners' (PCPs) knowledge, attitudes, and practice implications. Methods: Empirical studies were identified through relevant database searches (database inception to May 2020). Two authors evaluated the eligibility of studies, extracted and crosschecked data, and assessed the risk of bias. Results were synthesized in a narrative form. Results: Six studies of the 232 titles identified and screened were included. All studies were undertaken in the United States, with five conducted postlegislation in their respective states, and one study conducted in states that were both prelegislation and postlegislation. Five studies were quantitative, including four cross-sectional surveys, and one study was qualitative. Findings consistently demonstrated PCPs' overall lack of knowledge about BD, low level of comfort in discussing and managing patients in relation to dense breasts, and limited consensus on the most appropriate approach for managing women with dense breasts, particularly in relation to supplemental screening. Conclusions: This review highlights important gaps in PCPs' understanding of BD and confidence in having discussions with women about the implications of dense breasts. It identifies the need for high-quality research and the development of evidence-based guidelines to better support PCPs.

COVID-19 Misinformation Trends in Australia: Prospective Longitudinal National Survey

BACKGROUND

Misinformation about COVID-19 is common and has been spreading rapidly across the globe through social media platforms and other information systems. Understanding what the public knows about COVID-19 and identifying beliefs based on misinformation can help shape effective public health communications to ensure efforts to reduce viral transmission are not undermined.

OBJECTIVE

This study aimed to investigate the prevalence and factors associated with COVID-19 misinformation in Australia and their changes over time.

METHODS

This prospective, longitudinal national survey was completed by adults (18 years and above) across April (n=4362), May (n=1882), and June (n=1369) 2020.

RESULTS

Stronger agreement with misinformation was associated with younger age, male gender, lower education level, and language other than English spoken at home (P<.01 for all). After controlling for these variables, misinformation beliefs were significantly associated (P<.001) with lower levels of digital health literacy, perceived threat of COVID-19, confidence in government, and trust in scientific institutions. Analyses of specific government-identified misinformation revealed 3 clusters: prevention (associated with male gender and younger age), causation (associated with lower education level and greater social disadvantage), and cure (associated with younger age). Lower institutional trust and greater rejection of official government accounts were associated with stronger agreement with COVID-19 misinformation.

CONCLUSIONS

The findings of this study highlight important gaps in communication effectiveness, which must be addressed to ensure effective COVID-19 prevention.

The Psychological Impact of Hypertension During COVID-19 Restrictions: Retrospective Case-Control Study

BACKGROUND

It is unclear how people with hypertension are responding to the COVID-19 pandemic given their increased risk, and whether targeted public health strategies are needed.

OBJECTIVE

This retrospective case-control study compared people with hypertension to matched healthy controls during the COVID-19 lockdown to determine whether they have higher risk perceptions, anxiety, and vaccination intentions.

METHODS

Baseline data from a national survey were collected in April 2020 during the COVID-19 lockdown in Australia. People who reported hypertension with no other chronic conditions were randomly matched to healthy controls of similar age, gender, education, and health literacy level. A subset including participants with hypertension was followed up at 2 months after restrictions were eased. Risk perceptions, anxiety, and vaccination intentions were measured in April and June.

RESULTS

Of the 4362 baseline participants, 466 (10.7%) reported hypertension with no other chronic conditions. A subset of 1369 people were followed up at 2 months, which included 147 (10.7%) participants with hypertension. At baseline, perceived seriousness was high for both hypertension and control groups. The hypertension group reported greater anxiety compared to the controls and were more willing to vaccinate against influenza, but COVID-19 vaccination intentions were similar. At follow-up, these differences were no longer present in the longitudinal subsample. Perceived seriousness and anxiety had decreased, but vaccination intentions for both influenza and COVID-19 remained high across groups (>80%).

CONCLUSIONS

Anxiety was above normal levels during the COVID-19 lockdown. It was higher in the hypertension group, which also had higher vaccination intentions. Groups that are more vulnerable to COVID-19 may require targeted mental health screening during periods of greater risk. Despite a decrease in perceived risk and anxiety after 2 months of lockdown restrictions, vaccination intentions remained high, which is encouraging for the future prevention of COVID-19.

Getting the timing right: Women's views on the best time to announce changes to cancer screening policy recommendations

•

Women suggest communicating changes to screening programs 6–12 months before implementation.

•

Opportunities to be involved in consultation about changes are important.

•

Preference for information using evidence, with an option of more information.

•

Recognition that the mode of delivery should differ by age.

In December 2017, the Australian National Cervical Screening Program (NCSP) changed from 2-yearly cervical cytology to 5-yearly primary human papillomavirus (HPV) testing, starting at age 25 and with an exit test when aged 70–74. Women showed limited awareness of these changes prior to their implementation. We explored women’s preferences for how similar cancer screening changes could be communicated to the public in the future, including when, how, and using what methods. Six focus groups including 49 women aged 18–74 were conducted in November 2017. Focus groups were guided by information available on the NCSP website and information developed by the researchers. Generally, women suggested that communication of changes to cancer screening programs would ideally occur between 6 and 12 months ahead of their implementation and that they would like the opportunity to be involved in consultation about the changes. The NCSP website was described as answering basic questions, but also raising further questions for which there were no answers provided. Most groups preferred information which included evidence behind the changes and wanted an option of more information. Similar suggestions were made across all focus groups about how communications could be delivered, with recognition that the mode of delivery should differ by age. Women were still seeking information about the test itself and a symptom list, in order to be aware of these over the five-year period. These findings make an important and timely contribution which could help inform other countries considering making changes to their cancer screening programs in the future.

People's Experiences and Satisfaction With Telehealth During the COVID-19 Pandemic in Australia: Cross-Sectional Survey Study

Background

In response to the COVID-19 pandemic, telehealth has rapidly been adopted to deliver health care services around the world. To date, studies have not compared people’s experiences with telehealth services during the pandemic in Australia to their experiences with traditional in-person visits.

Objective

This study aimed to compare participants’ perceptions of telehealth consults to their perceptions of traditional in-person visits and investigate whether people believe that telehealth services would be useful after the pandemic.

Methods

A national, cross-sectional, community survey was conducted between June 5 and June 12, 2020 in Australia. In total, 1369 participants who were aged ≥18 years and lived in Australia were recruited via targeted advertisements on social media (ie, Facebook and Instagram). Participants responded to survey questions about their telehealth experience, which included a free-text response option. A generalized linear model was used to estimate the adjusted relative risks of having a poorer telehealth experience than a traditional in-person visit experience. Content analysis was performed to determine the reasons why telehealth experiences were worse than traditional in-person visit experiences.

Results

Of the 596 telehealth users, the majority of respondents (n=369, 61.9%) stated that their telehealth experience was “just as good as” or “better than” their traditional in-person medical appointment experience. On average, respondents perceived that telehealth would be moderately useful to very useful for medical appointments after the COVID-19 pandemic ends (mean 3.67, SD 1.1). Being male (P=.007), having a history of both depression and anxiety (P=.016), and lower patient activation scores (ie, individuals’ willingness to take on the role of managing their health/health care) (P=.036) were significantly associated with a poor telehealth experience. In total, 6 overarching themes were identified from free-text responses for why participants’ telehealth experiences were poorer than their traditional in-person medical appointment experiences, as follows: communication is not as effective, limitations with technology, issues with obtaining prescriptions and pathology results, reduced confidence in their doctor, additional burden for complex care, and inability to be physically examined.

Conclusions

Based on our sample’s responses, telehealth appointment experiences were comparable to traditional in-person medical appointment experiences. Telehealth may be worthwhile as a mode of health care delivery while the pandemic continues, and it may continue to be worthwhile after the pandemic.