Australian Behavioural Research in Cancer


New results

Centre for Health Research and Psycho-oncology (CHeRP), NSW

Improving psychosocial well-being in an outpatient oncology clinic

Although people with cancer suffer considerable psychosocial morbidity, much of it goes undetected and untreated by health care providers. While there are many valid and reliable self-report tools measuring cancer patients’ psychosocial issues, the feasibility of using them routinely in clinical practice has often been questioned. There is growing evidence that computer-based methods of survey administration are fast, robust, acceptable to cancer patients and feasible to implement in oncology clinics. They also enable patient self-report data to be collected, scored and fed back to health care providers in real time to enable issues of concern to be addressed during the consultation.

Allison Boyes, Afaf Girgis and colleagues undertook a pilot study to evaluate whether providing medical oncologists with regular printed feedback about their patients’ self-reported psychosocial well-being resulted in lower levels of patient anxiety, depression, perceived needs and fewer debilitating physical symptoms. Patients visiting the medical oncology outpatient department at one hospital completed a 15-20 minute touchscreen computer survey at their first four visits to the clinic. Each person was allocated to either the intervention or control group after completing the initial survey. For each patient in the intervention group, the oncologist received a printed feedback sheet prior to each consultation which summarised the individual’s responses to the most recently completed survey and recommended strategies for dealing with the issues identified. Results of the study indicated that patients in the intervention group were significantly more likely to report fewer debilitating symptoms and levels of anxiety, depression and perceived needs also decreased (non-significant) from the initial consultation to final follow-up. Providing medical oncologists with summarised information about patients’ self-reported well-being via a touchscreen computer survey in the waiting room may be an effective strategy for improving patient outcomes. 

Centre for Behavioural Research in Cancer (CBRC), VIC

Respiratory symptoms and staff exposure to second hand smoke in hospitality industries

The aim of this study was to assess the relationship between exposure to second-hand smoke (SHS) in the workplace and respiratory and sensory symptoms. This formed part of a study in which data were gathered by a telephone survey of 1,078 members (77% response rate) of the Australian Liquor, Hospitality and Miscellaneous Workers Union (Victoria).

Data were gathered from 382 respondents who worked at least 35 hours per week, indoors or in a vehicle, and were never smokers or ex-smokers who had quit over one year ago. Exposure to SHS at work was measured by the number of hours in the same room as someone who was smoking. After controlling for potential confounders, exposure to SHS at work for part of the day was significantly associated with an increased risk of wheeze (OR=4.26), frequent cough (OR=2.26), sore eyes (OR=3.77) and sore throat (OR=2.70). When we stratified the analysis according to whether workers had experienced a cold in the past four weeks, the risk of symptoms disappeared for those who had, and strengthened for those who had not. Among workers who had not experienced a cold, we found strong and dose response relationships between increasing levels of exposure to SHS at work and morning cough, frequent cough, sore eyes and sore throat, and a positive relationship for wheeze. These findings provide compelling evidence that Victorian indoor workers are adversely affected by exposure to SHS at work and underline the importance of workplace smoke-free policies in protecting the health of workers. This study, which was funded by VicHealth was conducted by CBRC researchers Melanie Wakefield, Melissa Cameron, Lisa Trotter, Tessa Letcher, Graeme Inglis and David Hill, plus Alistair Woodward (University of Otago), and is in press in the Journal of Occupational and Environmental Medicine. 

Centre for Cancer Control Research (CCCR) and the Tobacco Control Research and Evaluation Program (TCRE), SA

Progress in tobacco control 2002: Health omnibus survey

This report by TCRE used data from the health omnibus survey. The health omnibus survey is a state-wide annual survey of more than 3,000 respondents. The results revealed that smoking prevalence for the South Australian population was 24.1% in 2002 (unstandardised; all smokers). Smoking rates remained consistently higher for men than women. Most smokers made a quit attempt at some point and almost one-third of smokers made a quit attempt in the past year. Passive smoking remains a major public health concern, with a majority of the population being concerned about passive smoking, and a similar proportion reported being exposed to someone else’s cigarette smoke in the previous two weeks. Exposure was the highest in hotels and bars, where there are still little or no restrictions on smoking.

Analysis presented a detailed picture of the socio-economic predictors of smoking in South Australia using population trend data. A draft report, “Smoking and social inequalities in South Australia”, demonstrated that social inequalities are evident in the prevalence of smoking and involuntary exposure to tobacco smoke. Evidence about whether the difference between the groups is widening over time is mixed but warrants close monitoring.

Lung cancer trends in South Australia

CCCR assisted the Epidemiology Branch of the Department of Human Services to assess lung cancer trends in South Australia by histological type, as a means of evaluating cancer control initiatives. A three-fold increase in age-standardised lung cancer mortality had occurred in males between the 1950s and 1970s, followed by a decrease of approximately a quarter by the year 2000. This reduction was consistent with the decrease in smoking prevalence in Australian males in the latter part of the century. In females, an approximate three-fold increase in lung cancer mortality presented between the 1960s and 1980s, followed by a plateau in the 1990s. These trends also are consistent with historic trends in cigarette smoking in Australian women.

In both males and females, the ratio of adenocarcinomas to squamous carcinomas increased, potentially due at least in part, to changes in cigarette choice to varieties with a lower tar and nicotine yield. Compensatory smoking practices have been reported when these varieties are used, including deeper inhalation. Higher ratios of adenocarcinomas to squamous cell cancers were observed in females, younger patients, and residents of upper socio-economic areas. Notably, data from a South Australian household survey in 2002 pointed to a greater use of low-tar as opposed to high-tar cigarettes by residents with this socio-demographic profile. More favourable trends in lung cancer rates generally were observed in younger age groups, which hopefully will transfer to the older age groups, as these younger cohorts get older.

An audit of nutrition and cancer information in popular magazines

This audit of nine popular general or health-focussed magazines identified a total of 204 cancer related articles from 88 individual issues in press between February 2002 and January 2003. Of these, 39% related to cancer in general, 25% focussed on breast cancer, 18% on colorectal cancer, 14% on skin cancer, 13% on prostate cancer, 7% on lung cancer and the remainder on other less common cancers. Forty-seven per cent of all cancer related articles made some mention of nutrition. (The quality and accuracy of this information was not assessed.) Specific dietary recommendations (eg increasing vegetable consumption) were mentioned infrequently and advice was generally not specific to the type of cancer being discussed. Other cancer related lifestyle factors (obesity, sedentariness, and excess alcohol consumption) were rarely mentioned.

Given that popular magazines are a major source of health-related information for many people, more attention needs to be paid to working with the media to enhance communication about nutrition and cancer risk. Acknowledgments to Catherine Easterbrook who worked on this project during a student placement at The Cancer Council Australia South Australia.

Centre for Behavioural Research in Cancer Control (CBRCC), WA

Analysis of Western Australian and national data resulting from a population survey of 2,501 subjects concerning various attitudes towards cancer proceeds with aplomb. Papers continue to be prepared for submission to various peer-reviewed journals. Two recently prepared articles include one entitled “Metropolitan Australians’ perception of genetic testing for cancer”. The paper outlines results to suggest that the majority of metropolitan Australians are aware of genetic screening for cancers, are quite accepting of them and appear willing to subject themselves to genetic screening tests.

The second paper is entitled “Changes in Western Australians’ beliefs about cancer: 1964 to 2001”. The results suggest that Western Australians in 2001 are much better informed about cancer than they were in 1964. Some interesting results include a four-fold increase in the rates of people who have ever had a cancer check-up, and the virtual disappearance of a previously commonly held belief that cancer could be caused by receiving a physical ‘knock’.

Research in the pipeline


Art psychotherapy: its effect on the immunological and psychosocial functioning of cancer patients

Art therapy, the use of patient-created visual images and the exploratory conversations that ensue as a result of their creation, as the primary focus in emotional healing, has been used since before World War II. There has also been much interest in the impact of emotional state on immunological function and the positive impact of emotional support on psychological health and adjustment to cancer.

Christina Virago, under the supervision of Afaf Girgis and Margaret Dunkley, is undertaking an innovative project as part of her PhD, to assess the effects of art psychotherapy on the psychological and social coping skills and immune function of a group of people with non-metastatic malignant melanoma. The research will be a randomised controlled trial, with those in the intervention group taking part in weekly art psychotherapy sessions over a period of six months. Those in the control group will also meet on a weekly basis for informal conversation. At the beginning and end of the trial, and also at 12 months follow-up, all participants will complete a series of self-administered psychosocial questionnaires. Participants’ IgA levels and T-cell activity will also be tested at various intervals as a measure of their immune response. It is anticipated that participants taking part in art psychotherapy will have better psychosocial and immunological functioning post-intervention when compared to the control group. To date, most art therapy research has relied upon anecdotal evidence or case studies. It is hoped that this research will provide the scientific rigour research to establish the discipline within an acceptable medical paradigm.


Youth appraisal of anti-smoking advertisements: A comparative study in the United States, Australia and Britain

Melanie Wakefield is leading a study with Russil Durrant in CBRC and colleagues in the United States and Britain (funded by the US National Cancer Institute with support from VicHealth) to compare the similarity in how youth in the United States, Australia and Britain appraise anti-smoking advertisements with different characteristics. The study involved each participant viewing and evaluating a set of 10 anti-smoking ads (for an overall total of 50 ads) in a controlled experimental context using an audience response methodology. A structured telephone interview was completed one week after viewing the ads, in which recall and engagement with the ads by participants was evaluated.  Overall 615 grade eight, 10 or 12 youths from the US, Australia and Britain completed the protocol. The study has collected measures of ad appraisal (% of youth who rated the ad as a very good anti-smoking ad; % of youth who nominated the ad as the one that most stands out) and engagement (% of youth who recalled the ad at follow-up; % who discussed the ad with someone outside of the rating session; % who thought more about something in the ad between session and follow-up). Analyses are being undertaken to contrast the potential effectiveness of different advertising themes (health effects of smoking, secondhand smoke, industry manipulation, etc), executional styles (personal testimonial, negative visceral element) and target audiences (youth or general). The findings will be discussed with regard to the possibility of sharing anti-smoking ads among broadly similar cultures.

Unintended effects of advertising for nicotine replacement therapy and Zyban

Funded by NHMRC, this study is investigating whether youth exposure to television advertising for nicotine replacement therapy (NRT) and Zyban might result in increased perceptions of the ease of quitting smoking or decreased perceptions of addiction, leading youth to conclude that there is less of a problem with taking up smoking. This is consistent with research which found that optimism about quitting is a major predictor of trial and subsequent progression to heavier smoking among young people.

The study is premised on the fact that television advertising of NRT and Zyban will ipso facto reach more than its intended primary target group of smokers, so it is important to consider the responses of those at risk of taking up smoking, namely teenagers, to the advertising. The study will employ an audience response methodology where 495 youth who meet eligibility criteria are randomised within stage of quitting/stage of uptake to either 1. a control group, where they will view three ads promoting non-pharmacological methods of quitting, such as the Quitline; 2. an Experimental NRT condition, where they will view three ads promoting the gum and patch, or 3. an Experimental Zyban condition, where they will view three ads promoting Zyban (from New Zealand and USA). One-page rating forms will be completed by participants after viewing each ad twice, and at the end of the session, participants will complete a questionnaire which asks questions about perceptions of addiction; smoking health risks; perceived confidence in, and difficulty of quitting smoking; intention to smoke in future; and perceived need for help to quit smoking. By comparing responses to these questions between the groups, this study will furnish information to help assess potential risks of advertising for NRT and Zyban, alongside the established benefits.

Evaluation of the impact of a peer support program for cancer patients on adjustment to a cancer diagnosis

The Cancer Connect Program puts people in touch by telephone with a trained volunteer who has been through a similar cancer and treatment experience. This study aims to determine if cancer patients who participate in Cancer Connect are satisfied with the program they received. It will also examine what effect, if any, participation in Cancer Connect has on the experience of cancer treatment for program participants compared to those who did not take part.

This is a prospective quasi-experimental trial comprising two research arms: a Cancer Connect Group (newly diagnosed patients participating in the Cancer Connect program), and a Usual Care Control Group (newly diagnosed patients in Western Australia accessing an established professional cancer information and support telephone help line). Patients are recruited into the study by nurse counsellors and are interviewed by telephone, after the initial contact with the Cancer Information and Support Service (CISS), three months after initial CISS contact, using the Computer-Assisted Telephone Interviewing (CATI) program, by experienced interviewers blinded to the study group. Patients are currently being recruited and interviewed for this study which is being conducted by Victoria White and Trish Livingston.

A pilot test of shade intervention for secondary schools

Adolescents have a high knowledge of the risk of sun exposure in relation to skin cancer and appear resistant to traditional approaches to promoting sun protection. Further research is urgently needed to explore innovative approaches to intervening with this group. Suzanne Dobbinson and Melanie Wakefield recently conducted a pilot study exploring the feasibility of developing a shade intervention for secondary schools. VicHealth provided funds to test the development of shade-sail structures for two areas in a high-activity and relaxation area at one school. In January 2003 a school with suitable areas for shade development was recruited. A pre-test over two weeks in late February used photographic observation to assess students’ use of the pre-defined areas prior to the shade development. A number of delays and difficulties were experienced with the installation of the shade structures, which took until early April to complete. Nonetheless, the weather remained moderately warm and six days of post-test observations were completed prior to the end of term one. A complete analysis of the results is underway with some anecdotal evidence that students will utilise the shade under these purpose-built shade structures at least while weather is warm and for passive activities. The results of this study are invaluable to refining this intervention study and in seeking funding for a larger study to test efficacy.


Quit Media Campaign Evaluation: Jenny

The new Quit campaign, originally from WA, started in March this year featuring Jenny, a woman with lung cancer. The campaign was targeted primarily at younger women (18-24 years). The secondary target was older women in the 25-39 age group. An evaluation is currently underway, using the Morgan Natural Exposure Advertising Research methodology.

Community perceptions about tobacco control and the tobacco industry

Also under investigation are community opinions and attitudes about a range of (potential) tobacco control policies and the tobacco industry. Of specific interest is whether community attitudes have undergone any change in the period 1999 to 2002.

Review of cancer research outcomes in SA

The Cancer Council Australia South Australia has provided research funds totalling over $20m since 1989, mainly for project grants and fellowships with smaller amounts going to scholarships, data managers in hospitals, travel grants and the like. In order to provide feedback to the community who provides the funds and to inform development of research policy, we propose to review the returns on this investment in terms of impact on cancer control and possibly identify gaps. Citation analysis and journal impact factors will be considered, as will post-fellowship career paths and changes to policy, practice or curriculum resulting from research. Contacts, advice, references to similar work, etc would be very welcome, to


The Cancer Prevention Research Centre has recently obtained funding from Health Promotion Queensland for an eight-month project which aims to investigate factors that influence young Queensland women to initiate, maintain or stop smoking tobacco. The project involves a number of interrelated components which will provide information that will be triangulated to develop specific, evidence-based recommendations for strategies to reduce cigarette smoking among young women in Queensland. These components include:

  • a review of the scientific literature, specifically relating to young women and smoking;
  • review of relevant state, national and international tobacco control initiatives;
  • focus group discussions and in-depth interviews with young women to examine personal and social influences relating to smoking behaviour;
  • analysis of factors influencing young Queensland women’s smoking behaviour, using existing data from several national and state sources, including the Australian Longitudinal Study on Women’s Health;
  • web-based survey of knowledge and attitudes toward anti-smoking and smoking cessation messages among young women;
  • semi-structured telephone interviews with young women conducted through Women’s Health Queensland Wide’s Health Information Line, to explore knowledge and attitudes toward anti-smoking and smoking cessation messages; and
  • semi-structured telephone interviews with key service providers and key informants to investigate dissemination and implementation of anti-smoking and smoking cessation initiatives.

The resulting report will have specific, practical recommendations for ways to significantly reduce smoking among young Queensland women.


The Centre is currently participating in the Consumer Participation Project at the Cancer Foundation of Western Australia. Breast, colorectal and prostate cancer guidelines booklets so far have been evaluated in terms of consumer awareness, utilisation and perceptions of usefulness. The methodology has involved telephone interviews, postal surveys and focus groups with consumers who have been diagnosed with either breast, colorectal or prostate cancer. Consumers are also being invited to critique the guidelines and identify aspects that may not be meeting consumer needs. The research aims to inform the improvement of the various guidelines to make them more available and relevant to consumers’ needs.



Congratulations to Dilhani Bandaranayake who was awarded her PhD for her research entitled “Why do some non-melanocytic skin cancers reach an advanced stage before they are treated? The effect of delay and predictors of delay in presentation, referral and treatment of NMSC”.

In March, CHeRP hosted a workshop of national and international statisticians and methodologists to develop scoring, analyses and interpretation recommendations for the Supportive Care Needs Survey (SCNS). This was a follow-on from the workshop held in November 2002 on the practical aspects of needs assessment in oncology. The recommendations have been incorporated into a SCNS users’ manual.

CHeRP has had a number of recent grant successes. Afaf Girgis, Chris Paul and Claire Johnson were awarded a seeding grant from Effective Healthcare Australia to conduct research into the attitudes and barriers to appropriate and timely referral of cancer patients to palliative care. Afaf Girgis, Paul Glare, Amanda Neil and Sibilah Breen were awarded a grant from the MBF Health Research Awards to conduct a trial of supportive care strategies for advanced cancer patients in NSW.

CHeRP staff presented three papers at the 2nd Australian Tobacco Control Conference, held in Melbourne on 9-11 April. Paul presented ‘Smoking care provision in NSW public hospitals’; Wiggers, Paul and Walsh presented ‘Pro-active delivery of smoking cessation strategies to smokers in the community: Feasibility and acceptability’; and Walsh presented ‘Community attitudes towards environmental tobacco smoke in New South Wales bars and other licensed premises’.

Afaf Girgis and Allison Boyes attended the 6th World Congress of Psycho-oncology in Banff, Canada, and presented a poster on CHeRP’s population-based studies of cancer survivors’ physical and psychosocial well-being and another poster promoting the various applications of the SCNS.

Allison Boyes visited the American Cancer Society’s Behavioural Research Centre in Atlanta, USA, and gave an invited presentation on CHeRP’s research in cancer survivorship.


CBRC staff presented nine papers at the 2nd Australian Tobacco Control Conference: Wakefield presented ‘The cigarette pack as an image: Implications for tobacco control policy’, ‘Relation between anti-smoking advertising and youth smoking in the United States’ and ‘Youth appraisal of anti-smoking advertisements: a comparative study in Australia, the United States and Britain’; Cameron presented ‘Exposure to secondhand smoke (SHS) at work: a survey of members of the Australian Liquor, Hospitality and Miscellaneous Worker’s Union’; Dixon presented ‘Smoking in movies: Does it matter who does the smoking?’ and ‘Is on-screen smoking by teenagers’ favourite actors and actresses associated with teenagers’ beliefs and behaviour toward smoking?’; Durrant presented ‘Tobacco in the News: an analysis of newspaper coverage of tobacco issues in Australia, 2001’; Letcher presented ‘Adaptation to mandated restrictions on smoking in dining areas: Results of an internet survey’; and, Letcher presented, ‘Bans on tobacco advertising at point of sale’.

Helen Dixon gave two presentations at the International Communications Conference in San Diego in May. Dixon, Borland and Paxton presented ‘Smoking in movies: does it matter who does the smoking?’ and Dixon, Hill, Karoly, Jolley and Aden presented ‘Solar UV forecasts: an evaluation of their impact on adults’ sun protection behaviour’. 


TCRE has undergone some staff changes in the last few months. Sophie Kriven has left the team to travel extensively through the US, Canada and Europe. She has been replaced by Sinéad Quinn. Sinéad comes to the team from an academic background, with specific experience in the area of psychology. 


Neville Owen attended the American College of Sports Medicine Conference in San Francisco, 38-31 May 2003.  Neville has also been invited to speak at the Conference of the European College of Sports Science in Salzburg, 9-12 July 2003 and the Second Conference of the International Society for Behavioural Nutrition and Physical Activity in Quebec City, Canada, 17-20 July 2003.

Congratulations to Liane McDermott. Formerly the Senior Research Officer with the Centre, Liane began her PhD candidacy in March this year with ‘Reducing cigarette smoking among young women’, and as if this is not enough of a challenge, Liane will be adding motherhood to her busy life in October.

The Centre is currently advertising for two research fellow positions for a fixed-term of two years: a Research Fellow – Behavioural Studies of Physical Activity; and a Research Officer/Fellow – Behavioural Studies of Cancer Prevention. Successful applicants will commence in late June.

Welcome to Alexia Lennon. Alexia joined the Centre in early May as the Project Co-ordinator for the Centre’s new Young Women and Smoking Project.


Rob Donovan and Narelle Weller presented at the 2nd Australian Tobacco Control Conference. Donovan’s presentation was entitled ‘Developing effective communication strategies in mass media’. Discussed was recent progress the Centre had made on the early formative research techniques for “getting the right message and getting the message right” in relation to successful health awareness media campaigns. Weller presented a paper entitled ‘Incidental smoking in the media’. It described the results of research over the past year to identify the frequency and characteristics of smoking incidences at media targeted to the 18 to 30 year old age group. Outlined were the methodologies used to investigate various media including newspapers, magazines, movies, television programs, televised sporting events, music videos, music lyrics and websites.

Thanks to Anne Gibbs, Melanie Wakefield, Owen Carter, Cathy Swart, and Kerri Beckmann for their contributions.

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