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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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