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The recent scandal involving Tokyo Medical University’s practice of restricting the number of incoming students, primarily female, by systematically lowering their entrance exam scores has once again shone a spotlight on the issue of gender discrimination in Japan. The bulk of the media coverage to date has centered on the manner in which the female applicants to the university have been treated unfairly and how societal perceptions of women’s roles in the workplace may be in need of significant revision. In the present paper, the author will provide an overview of this aspect of the situation and suggest potential means to be taken by the university to redress its actions. Additionally, the author will examine another extremely important aspect of the scandal, namely, how the university was able to conduct its discriminatory practice unchecked for over a decade, a topic that has received less attention. Possible means through which similar scandals may be avoided in the future will also be discussed.

Following publication of the original article [1], the author attempted to provide an overview of a scandal occurring at a Japanese university over its practice of lowering the scores of (primarily) female applicants and offered possible suggestions as to how to prevent this from reoccurring.

Neurocognitive impairment is being increasingly recognized as an important issue in patients with cancer who develop cognitive difficulties either as part of direct or indirect involvement of the nervous system or as a consequence of either chemotherapy-related or radiotherapy-related complications. Brain radiotherapy in particular can lead to significant cognitive defects. Neurocognitive decline adversely affects quality of life, meaningful employment, and even simple daily activities. Neuroprotection may be a viable and realistic goal in preventing neurocognitive sequelae in these patients, especially in the setting of cranial irradiation. Lithium is an agent that has been in use for psychiatric disorders for decades, but recently there has been emerging evidence that it can have a neuroprotective effect. This review discusses neurocognitive impairment in patients with cancer and the potential for investigating the use of lithium as a neuroprotectant in such patients.

IntroductionBreast cancer risk can be substantially reduced with risk-reducing medications (RRMeds). Despite their efficacy, and guidelines which support their use for women at substantially increased risk of breast cancer, they are underused. Barriers to their use in Australia include a lack of awareness of RRMeds by women and clinicians, and a primary care workforce that reports a lack of knowledge and confidence in discussing and/or prescribing these medications. In contrast, Australian clinicians have reported specialist support and guidance as a key facilitator. The Preventing Cancer with Medications (PCMed) Telehealth Service was therefore developed to provide this specialist support and to bridge the evidence–implementation gap. The PCMed Service endeavours to increase the appropriate use of RRMeds and support women and their doctors throughout treatment. The aim of this research is to evaluate the effectiveness, adoption, acceptability, feasibility, fidelity and cost of this new Service, and to determine any adaptations that might be required.Methods and analysisThe research uses a mixed methods approach. Effectiveness of the PCMed Service will be evaluated by determining whether the PCMed Service is associated with increased uptake of RRMeds compared with historical data. Secondary outcomes include: adoption of the Service, specifically, the proportion of women who attend a PCMed Service consultation; acceptability of the Service for clients and referring clinicians (using a brief survey and semistructured interviews); feasibility and fidelity by evaluating the adherence to the planned Service processes; and the cost, by reporting the difference between funding received per woman and the cost for service delivery.Ethics and disseminationThis study was approved by the institutional Human Research Ethics Committee (EC00235): HREC/101142/PMCC. The findings will inform future iterations of the Service prior to scaling up. Research findings will be disseminated at scientific meetings and in peer-reviewed journals.Trial registration numberISRCTN15718519.

Long-term survivors of childhood, adolescent and young adult (AYA) malignancies with past exposure to potentially cardiotoxic treatments are at risk of peripartum cardiac dysfunction. Incidence and risk factors for peripartum cardiac dysfunction and maternal cardiac outcomes in this population were investigated. Eligible long-term survivors were aged <30 years at cancer diagnosis, with ≥1 pregnancy occurring ≥5 years after diagnosis. “Peripartum” cardiac events were defined as occurring within pregnancy or ≤5months after delivery. Cardiac events were classified “symptomatic” or “subclinical”. “Peripartum cardiomyopathy” (PPCM) was defined as symptomatic dysfunction without prior cardiac dysfunction. Of 64 eligible women, 5 (7.8%) had peripartum cardiac events: 3 symptomatic, 2 subclinical. Of 110 live births, 2 (1.8%, 95% CI 0.2–6.4) were defined as PPCM: Significantly greater than the published general population incidence of 1:3000 (p < 0.001), representing a 55-fold (95% CI 6.6–192.0) increased risk. Risk factor analyses were hypothesis-generating, revealing younger age at cancer diagnosis and higher anthracycline dose. Postpartum, cardiac function of 4 women (80%) failed to return to baseline. In conclusion, peripartum cardiac dysfunction is an uncommon but potentially serious complication in long-term survivors of paediatric and AYA malignancies previously treated with cardiotoxic therapies. Peripartum cardiac assessment is strongly recommended for at-risk patients.

This correspondence is in response to the Letter to the Editor “Evaluating Proton Versus Photon Therapy: A Call for Nuanced Decision‐Making”. A balanced evidence‐based approach that is patient‐centred is needed when deciding between proton versus photon radiotherapy.

Proton beam therapy (PBT) is increasingly used to treat cancers, especially in the paediatric and adolescent and young adult (AYA) population. As PBT becomes more accessible, determining when PBT should be used instead of photon irradiation can be difficult. There is a need to balance patient, tumour and treatment factors when making this decision. Comparing the dosimetry between these two modalities plays an important role in this process. PBT can reduce low to intermediate doses to organs at risk (OAR), but photon irradiation has its dosimetric advantages. We present two cases with brain tumours, one paediatric and one AYA, in which treatment plan comparison between photons and protons showed dosimetric advantages of photon irradiation. The first case was an 18‐month‐old child diagnosed with posterior fossa ependymoma requiring adjuvant radiotherapy. Photon irradiation using volumetric modulated arc therapy (VMAT) had lower doses to the hippocampi but higher doses to the pituitary gland. The second case was a 21‐year‐old with an optic pathway glioma. There was better sparing of the critical optic structures and pituitary gland using fractionated stereotactic radiation therapy over PBT. The dosimetric advantages of photon irradiation over PBT have been demonstrated in these cases. This highlights the role of proton‐to‐photon comparative treatment planning to better understand which patients might benefit from photon irradiation versus PBT. This report describes two paediatric/adolescent and young adult (AYA) brain tumour cases demonstrating the dosimetric advantages of photon irradiation over proton beam therapy. This highlights the role of proton‐to‐photon comparative treatment planning to better understand which patients might benefit from photon irradiation versus proton beam therapy.

Proton‐beam therapy (PBT) is a cutting‐edge radiation therapy modality that is currently not available in Australia. Comparative photon‐proton (CPP) planning is required for the medical treatment overseas programme (MTOP) and will be required for access to PBT in Australia in the future. Comparative planning brings professional development benefits to all members of the radiation therapy team. This service was also created to support future proposals for a PBT facility in Victoria. We report our experience developing an in‐house CPP service at Peter MacCallum Cancer Centre. A set of resources to support CPP planning was established. Training of relevant staff was undertaken after which an in‐house training programme was developed. A standard protocol for PBT planning parameters was established. All CPP plans were reviewed. Future goals for the CPP planning programme were described. In total, 62 cases were comparatively planned over 54 months. Of these, 60% were paediatric cases, 14% were adolescents and young adults (15–25 years) and 26% were adults. The vast majority (over 75%) of patients comparatively planned required irradiation to the central nervous system including brain and cranio‐spinal irradiation. A variety of proton plans were reviewed by international PBT experts to confirm their deliverability. Our team at Peter MacCallum Cancer Centre has gained significant experience in CPP planning and will continue to develop this further. Local expertise will help support decentralisation of patient selection for proton treatments in the near future and the PBT business case in Victoria. Comparative planning brings professional development benefits to all members of the radiation therapy team. This service was also created to support future proposals for a Proton‐beam therapy facility in Victoria. We report our experience developing an in‐house comparative photon‐proton planning service at Peter Mac.

Stereotactic ablative body radiotherapy (SABR) is widely used to treat inoperable stage 1 non-small-cell lung cancer (NSCLC), despite the absence of prospective evidence that this type of treatment improves local control or prolongs overall survival compared with standard radiotherapy. We aimed to compare the two treatment techniques. We did this multicentre, phase 3, randomised, controlled trial in 11 hospitals in Australia and three hospitals in New Zealand. Patients were eligible if they were aged 18 years or older, had biopsy-confirmed stage 1 (T1–T2aN0M0) NSCLC diagnosed on the basis of 18F-fluorodeoxyglucose PET, and were medically inoperable or had refused surgery. Patients had to have an Eastern Cooperative Oncology Group performance status of 0 or 1, and the tumour had to be peripherally located. Patients were randomly assigned after stratification for T stage and operability in a 2:1 ratio to SABR (54 Gy in three 18 Gy fractions, or 48 Gy in four 12 Gy fractions if the tumour was <2 cm from the chest wall) or standard radiotherapy (66 Gy in 33 daily 2 Gy fractions or 50 Gy in 20 daily 2·5 Gy fractions, depending on institutional preference) using minimisation, so no sequence was pre-generated. Clinicians, patients, and data managers had no previous knowledge of the treatment group to which patients would be assigned; however, the treatment assignment was subsequently open label (because of the nature of the interventions). The primary endpoint was time to local treatment failure (assessed according to Response Evaluation Criteria in Solid Tumors version 1.0), with the hypothesis that SABR would result in superior local control compared with standard radiotherapy. All efficacy analyses were based on the intention-to-treat analysis. Safety analyses were done on a per-protocol basis, according to treatment that the patients actually received. The trial is registered with ClinicalTrials.gov (NCT01014130) and the Australia and New Zealand Clinical Trials Registry (ACTRN12610000479000). The trial is closed to new participants. Between Dec 31, 2009, and June 22, 2015, 101 eligible patients were enrolled and randomly assigned to receive SABR (n=66) or standard radiotherapy (n=35). Five (7·6%) patients in the SABR group and two (6·5%) in the standard radiotherapy group did not receive treatment, and a further four in each group withdrew before study end. As of data cutoff (July 31, 2017), median follow-up for local treatment failure was 2·1 years (IQR 1·2–3·6) for patients randomly assigned to standard radiotherapy and 2·6 years (IQR 1·6–3·6) for patients assigned to SABR. 20 (20%) of 101 patients had progressed locally: nine (14%) of 66 patients in the SABR group and 11 (31%) of 35 patients in the standard radiotherapy group, and freedom from local treatment failure was improved in the SABR group compared with the standard radiotherapy group (hazard ratio 0·32, 95% CI 0·13–0·77, p=0·0077). Median time to local treatment failure was not reached in either group. In patients treated with SABR, there was one grade 4 adverse event (dyspnoea) and seven grade 3 adverse events (two cough, one hypoxia, one lung infection, one weight loss, one dyspnoea, and one fatigue) related to treatment compared with two grade 3 events (chest pain) in the standard treatment group. In patients with inoperable peripherally located stage 1 NSCLC, compared with standard radiotherapy, SABR resulted in superior local control of the primary disease without an increase in major toxicity. The findings of this trial suggest that SABR should be the treatment of choice for this patient group. The Radiation and Optometry Section of the Australian Government Department of Health with the assistance of Cancer Australia, and the Cancer Society of New Zealand and the Cancer Research Trust New Zealand (formerly Genesis Oncology Trust).