DES Action Australia‐NSW Email 1 October 2009 Submission Response to Discussion Paper on achieving the directions established in the proposed NATIONAL SAFETY AND QUALITY FRAMEWORK Carol Devine Coordinator, DES Action Australia‐NSW Item of Comment: Strategy 1.2 Increase health literacy a. Supporting patients and consumers to take greater personal responsibility for their health care and obtain and use the information that is available to them. Listed Question for Response: No: 5 What are the main barriers in your work to improve safety and quality? Could any of these be addressed by national coordination? ‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐‐ Background Diethylstilboestrol (DES) is a synthetic oestrogen that was developed to supplement a woman’s natural oestrogen production. It was first prescribed in 1938 for women experiencing miscarriages or premature deliveries and originally considered effective and safe. In 1971 physicians were advised to stop prescribing DES to pregnant women because it was linked to a rare vaginal/cervical cancer in female offspring. Since 1971 research has shown: • Women prescribed DES while pregnant, known as DES mothers, are at 30% increased risk for breast cancer and require annual mammography and clinical breast examinations. • Women exposed to DES before birth (in the womb), known as DES daughters, are at increased risk for clear cell adenocarcinoma (CCA) of the vagina and cervix, 80% increased risk of breast cancer after age 40, reproductive tract structural differences, pregnancy complications and infertility. The risk for developing CCA is 1:1000 DES daughters. Although DES daughters appear to be at highest risk for clear cell cancer in their teens and early 20s, cases have been reported in the 30‐50 age groups [ http://obgyn.bsd.uchicago.edu/registry.html#accessions ] . This cancer is aggressive; it can be symptomless; it is not always detected by the usual Pap smear and it should be detected early. DES daughters require special annual “DES examinations”, along with annual mammography and clinical breast examinations. They require high‐risk care during pregnancy. • Men exposed to DES before birth (in the womb), known as DES sons, are at risk for non‐ cancerous epididymal cysts (cysts behind the testicles). Researchers are still following the health of the DES exposed population to determine whether other health problems occur with age. There may be many people who do not know whether they were exposed to DES and some women may not remember taking DES. DES information is important because people who were exposed must be vigilant about their own health care – to detect cancers early, demand high risk obstetric care when pregnant and factor in their exposure when making decisions about HRT use. It is as much part of a person’s medical history as a family history toward heart disease or diabetes. The Adverse Drug Reactions Unit of the Therapeutic Goods Administration (TGA) has data of 18 case reports of DES associated cancer. The failure to report cases has been acknowledged. With the known risk of 1:1000 DES daughters developing the associated cancer, this means there are conservatively at least 18,000 DES daughters, the equivalent number of DES sons and 36,000 DES mothers, thus totalling at least 72,000 Australians affected. There has been refusal by the TGA to complete regular reciprocal cross‐checks of Australian cases that have been reported to the International DES Registry, held in Chicago, USA. There are 40 cases of the DES cancer type in the <50 age group held in Australian Institute of Health and Welfare data. However, these cases have not been investigated regarding DES exposure. Prior to the DES problem, the cancer type associated to DES was rare and typically occurred in post‐menopausal women. In view of this, a maximum estimate could stand at 160,000 DES daughters, DES mothers and DES sons in Australia. COMMENT Item of Comment: Strategy 1.2 Increase health literacy a. Supporting patients and consumers to take greater personal responsibility for their health care and obtain and use the information that is available to them. Many Australians are still today unaware of having been DES exposed and unaware of the health danger of DES. Almost all DES exposed enquirers to DES Action Australia‐NSW have learnt about their DES exposure by chance via intermittent media articles, rather than via government health information. Government health information about DES is positioned in the background, whereby one would have to know about the danger of DES and its health implications in the first instance, in order to realise any need to research this health topic in government health information. Without attempt to make DES information appropriately available in public health promotion and education campaigns, the Australian population is deprived of the right of knowing the possibility of having been DES exposed. The great majority of patients and consumers who are DES exposed are unable to take ANY personal responsibility for their health care because information is not delivered to them appropriately and consequently unavailable to them. Information about DES requires promotion in public health programs and education campaigns. Listed Question for Response: No: 5 What are the main barriers in your work to improve safety and quality? Could any of these be addressed by national coordination? The main barrier in improving safety and quality in the health care of DES exposed Australians, including the health care of many unknowing victims of DES exposure, is the current national advice that the promotion of DES information is inappropriate as it is likely to create anxiety in women who are unsure of having been DES exposed. This barrier could easily be addressed by: • a national effort towards giving greater attention to the rights of Australians to be appropriately informed about DES. • national consultation with the US Centers for Disease Control [ www.cdc.gov/des ] and US experts in the field of DES research on the matter of the appropriateness and potential health benefits of promoting DES information in public health programs and education campaigns. (The USA public education campaign has addressed the needs of women who are unsure of having been exposed to DES). • the establishment of a nationally coordinated task force to educate the public and health care providers about DES.