Melbourne School of Population and Global Health - Research Publications

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    Australian clinicians and chemoprevention for women at high familial risk for breast cancer
    Keogh, LA ; Hopper, JL ; Rosenthal, D ; Phillips, K-A (BMC, 2009-05-04)
    OBJECTIVES: Effective chemoprevention strategies exist for women at high risk for breast cancer, yet uptake is low. Physician recommendation is an important determinant of uptake, but little is known about clinicians' attitudes to chemoprevention. METHODS: Focus groups were conducted with clinicians at five Family Cancer Centers in three Australian states. Discussions were recorded, transcribed and analyzed thematically. RESULTS: Twenty three clinicians, including genetic counselors, clinical geneticists, medical oncologists, breast surgeons and gynaecologic oncologists, participated in six focus groups in 2007. The identified barriers to the discussion of the use of tamoxifen and raloxifene for chemoprevention pertained to issues of evidence (evidence for efficacy not strong enough, side-effects outweigh benefits, oophorectomy superior for mutation carriers), practice (drugs not approved for chemoprevention by regulatory authorities and not government subsidized, chemoprevention not endorsed in national guidelines and not many women ask about it), and perception (clinicians not knowledgeable about chemoprevention and women thought to be opposed to hormonal treatments). CONCLUSION: The study demonstrated limited enthusiasm for discussing breast cancer chemoprevention as a management option for women at high familial risk. Several options for increasing the likelihood of clinicians discussing chemoprevention were identified; maintaining up to date national guidelines on management of these women and education of clinicians about the drugs themselves, the legality of "off-label" prescribing, and the actual costs of chemopreventive medications.
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    Women’s contraceptive decision-making: juggling the needs of the sexual body and the fertile body
    Keogh, Louise A. (The Haworth Press, Inc., 2005)
    The contradictions faced by women in the area of fertility management justify an in-depth qualitative study of contraceptive use. The experience of needing emergency contraception (EC) is an opportunity to study decision-making about fertility management. Thirty two in-depth interviews were conducted with users of EC recruited in Melbourne, Australia. Women were juggling the needs of the sexual body and the fertile body. The sexual body was expected to be available in women’s relationships, and the fertile body required protection from pregnancy in the present and preservation for the future. The needs of these two bodies were very often in conflict and women chose to resolve this conflict in subtly different ways; three strategies were identified. Some women chose to make sexual availability and security from pregnancy a priority; others felt forced to sacrifice sexual availability and security from pregnancy; and a final group chose to make the protection of the fertile body for the future a priority. This study provides a starting point for developing a context-based, woman-centered understanding of the experience of fertility management for women in developed countries.
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    Understandings of the 'natural' body: a comparison of the views of users and providers of emergency contraception
    Keogh, Louise A. (CSIRO, 2005)
    Background: 'Natural' is a pervasive discourse with mixed meanings in contemporary society. I was interested in how users and providers of emergency contraception conceptualised the 'natural' body in contraceptive decision making.Method: Thirty-two users and 19 providers of emergency contraception from three sites in metropolitan Melbourne were interviewed, or participated in focus groups, about emergency contraceptive use, contraceptive decision making and perceptions of risk. The qualitative data were transcribed and coded to identify the key ways that both users and providers perceived the 'natural' body.Results: Providers and users adopted different frameworks for interpreting the discourse of the 'natural' body. Thirteen of the 32 users identified the 'natual' body as a factor in their decision making. They identified a 'natural' body as a body experiencing no interruption with ovulation, and/or free from unwanted side effects. Six of the 13 women who discussed the 'natural' body used a contraceptive that allowed them to preserve their natural body (e.g. condoms). The remaining seven women identified it as an ideal that they could not achieve. Providers in general discredited the idea of a 'natural' body and instead conceptualised contraceptive decision making as a 'simple' risk-benefit anaysis.Conclusions: The differences between the two groups can be understood in a number of different ways. The important conclusion however, is that the different perspectives present a potential barrier to effective communication in the contraceptive consultation, and may be able to be resolved through the development of an embodied risk-benefit analysis that may be meaningful to both groups.
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    A qualitative study of women's use of emergency contraception
    Keogh, Louise A. ( 2005)
    BACKGROUND: While the use of emergency contraception (EC) is becoming more widespread in Australia, little is known about the reasons for, and the social context of, this use. METHODS: In order to explore the use of EC from the perspective of users, a qualitative study was conducted with women presenting to one of three health care settings in Melbourne, Australia for EC. RESULTS: Thirty-two women ranging in age from 18 to 45 years were interviewed. While a number of themes were discussed with the women, this paper reports on four ‘types of users’ of EC identified from the data. ‘Controllers’ experienced failure of their contraceptive method and were very uncomfortable needing EC. They changed their contraceptive strategy in an attempt to avoid needing EC in the future. ‘Thwarted controllers’ were similar to controllers except that they could not improve their contraceptive strategy due to medical or social limitations. ‘Risk takers’ saw the use of EC as a component of their overall contraceptive strategy. They did not rely on EC regularly, but were comfortable to use it occasionally when the need arose. A final group of women were ‘caught short’ by a sexual experience that was unplanned and therefore they did not manage to use their chosen contraceptive strategy. CONCLUSIONS: The findings from this study challenge the assumptions that are often made about the users of EC and highlight the need to acknowledge the different ways that women make sense of, and make decisions about, contraception.
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    Uptake of offer to receive genetic information about BRCA1 and BRCA2 mutations in an Australian population-based study
    Keogh, Louise A. ; Southey, Melissa C. ; Maskiell, Judi ; Young, Mary-Anne ; Gaff, Clara L. ; Kirk, Judy ; Tucker, Katherine M. ; Rosenthal, Doreen ; McCredie, Margaret R. E. ; Giles, Graham G. ; Hopper, John L. (American Association for Cancer Research, 2004)
    Research on the utilization of genetic testing services for mutations in BRCA1 and BRCA2 has focused on women with a strong family history of breast and ovarian cancer. We conducted a population-based case-control-family study of Australian women diagnosed with invasive breast cancer before age 40 years, unselected for family history, and tested for germ line mutations in BRCA1 and BRCA2. Case subjects found to carry a deleterious mutation and their relatives who had given a research blood sample were informed by mail that the study had identified “genetic information” and were offered the opportunity to learn more. Those interested were referred to a government-funded family cancer clinic. Of 94 subjects who received the letter, 3 (3%) did not respond and 38 (40%) declined to learn their result (16 declined the referral, 10 accepted but did not attend a clinic, and 12 attended a clinic but declined testing), and 12 (13%) remain “on hold”. The remaining 41 (44%) chose to learn their result (3 of whom already knew their mutation status). There was no evidence that the decision to learn of mutation status depended on age, gender, family history, or having been diagnosed with breast cancer. Of 19 families with more than one participant, in 11 (58%) there was discordance between relatives in receiving genetic results.