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Malignant Disease

Last updated 31 May 2026 ยท Oncology

๐Ÿ“‹ Key Information Summary

๐Ÿ“‹
  • Malignant neoplasms are characterised by uncontrolled proliferation, local invasion, and metastatic capacity โ€” distinguishing them from benign tumours which grow by expansion and lack these features.
  • In Australia, approximately 165,000 new cancers are diagnosed annually; skin cancer (melanoma and keratinocyte cancers) remains the most common, followed by prostate, breast, colorectal, and lung cancers (AIHW 2024).
  • Benign vs malignant differentiation relies on key histological features: cellular atypia, mitotic activity, invasion of basement membrane, and ability to metastasise.
  • Childhood cancers are rare (~1,000 cases/year in Australia) but are the leading cause of disease-related death in children aged 1โ€“14 years; persistent unexplained symptoms warrant urgent investigation.
  • Red flags in children include unexplained bruising, persistent bone pain, new limp, unexplained weight loss, proptosis, unexplained masses, and persistent unexplained fevers lasting >2 weeks.
  • Paraneoplastic syndromes are systemic manifestations caused by the tumour but not by direct mass effect โ€” they may be the presenting feature of an occult malignancy and include endocrine, neurological, dermatological, and haematological manifestations.
  • Common paraneoplastic syndromes include SIADH (lung), Cushing syndrome (SCLC, carcinoid), hypercalcaemia of malignancy (squamous cell cancers, myeloma), and Lambert-Eaton myasthenic syndrome (SCLC).
  • Occupational carcinogen exposure remains an important preventable cause of cancer; asbestos (mesothelioma, lung cancer), benzene (leukaemias), and UV radiation are major occupational hazards in Australia.
  • A two-week-wait approach is recommended for any clinical suspicion of malignancy โ€” do not delay referral for investigation of persistent, unexplained symptoms lasting >3 weeks.
  • Aboriginal and Torres Strait Islander Australians experience 1.4 times higher cancer incidence and 1.8 times higher cancer mortality compared with non-Indigenous Australians, with later-stage diagnosis and lower access to treatment.
  • General practitioners play a pivotal role in early detection, timely referral, shared-care coordination, and survivorship follow-up of patients with malignant disease.
  • All suspected occupational cancers should be documented and referred to state-based workers' compensation schemes; Safe Work Australia maintains the National Hazardous Substances Register.

Introduction & Australian Epidemiology

Malignant disease โ€” cancer โ€” encompasses a diverse group of diseases characterised by the uncontrolled growth and spread of abnormal cells. The recognition and clinical approach to malignancy in general practice is a cornerstone of early detection, timely referral, and improved patient outcomes. General practitioners are often the first point of contact for patients with symptoms suggestive of cancer and play a critical role throughout the cancer continuum from screening and diagnosis through to survivorship and palliative care.

In Australia, cancer is a major public health burden. According to the Australian Institute of Health and Welfare (AIHW), an estimated 165,000 new cancer cases were diagnosed in 2023, and cancer remains the second leading cause of death nationally. The five most commonly diagnosed cancers in Australia are:

  • Skin cancer (melanoma and keratinocyte cancers) โ€” Australia has the highest incidence of melanoma worldwide, with approximately 18,000 melanoma diagnoses annually.
  • Prostate cancer โ€” ~25,000 new cases per year; the most commonly diagnosed non-skin cancer in men.
  • Breast cancer โ€” ~21,000 new cases per year; the most commonly diagnosed non-skin cancer in women.
  • Colorectal cancer โ€” ~15,500 new cases per year; the National Bowel Cancer Screening Program (NBCSP) provides faecal immunochemical testing (FIT) to Australians aged 45โ€“74.
  • Lung cancer โ€” ~14,000 new cases per year; remains the leading cause of cancer death despite advances in treatment.

Survival outcomes have improved markedly over the past three decades. The five-year relative survival for all cancers combined in Australia is now approximately 70%, up from 52% in the period 1986โ€“1990. However, significant disparities persist โ€” particularly for Aboriginal and Torres Strait Islander Australians, those in rural and remote areas, and populations with lower socioeconomic status.

The general practice approach to malignant disease centres on maintaining a high index of clinical suspicion for red-flag presentations, initiating appropriate investigations without delay, facilitating rapid referral to specialist services, and coordinating multidisciplinary care.

โš ๏ธ
Clinical pearl: The single most important skill in early cancer detection is pattern recognition โ€” knowing which constellations of symptoms, signs, and risk factors warrant urgent investigation versus watchful waiting. A persistent, unexplained symptom lasting >3 weeks in an adult should prompt consideration of malignancy.

Benign vs Malignant Characteristics

Distinguishing benign from malignant neoplasms is fundamental to clinical decision-making. While definitive diagnosis requires histopathological assessment, clinical features can provide important clues that guide urgency of investigation and referral.

Key Distinguishing Features

Feature Benign Malignant
Growth pattern Expansile โ€” pushes adjacent tissue aside; often encapsulated Infiltrative โ€” invades and destroys adjacent tissue; no capsule
Rate of growth Usually slow; may plateau or regress Variable but generally progressive; may be rapid (e.g. high-grade lymphoma) or indolent (e.g. follicular thyroid carcinoma)
Cellular differentiation Well-differentiated; closely resembles tissue of origin Ranges from well-differentiated to anaplastic (poorly differentiated); higher grade = more aggressive
Mitotic figures Few; normal mitoses Numerous; may show atypical (tripolar, multipolar) mitoses
Nuclear features Uniform nuclei; low nuclear-to-cytoplasmic ratio Pleomorphic nuclei; high nuclear-to-cytoplasmic ratio; prominent nucleoli
Metastasis Does not metastasise Can metastasise via lymphatic, haematogenous, or transcoelomic routes
Recurrence Rare after complete excision May recur locally or distantly even after apparent complete resection
Systemic effects Generally local effects only (mass effect) Cachexia, paraneoplastic syndromes, immune suppression

Clinically Indeterminate Lesions

Several clinical scenarios present with features that are ambiguous between benign and malignant:

  • Breast lumps: Fibroadenomas (mobile, smooth, rubbery) vs carcinoma (fixed, irregular, hard). All new breast lumps in women >30 years require triple assessment (clinical examination, imaging, ยฑ biopsy).
  • Pigmented skin lesions: Melanocytic naevi vs melanoma. The ABCDE criteria (Asymmetry, Border irregularity, Colour variation, Diameter >6 mm, Evolution) and the "ugly duckling" sign guide referral.
  • Thyroid nodules: The majority (90โ€“95%) are benign. Ultrasound characteristics (TI-RADS scoring) and fine-needle aspiration biopsy (FNAB) guide management per the Royal Australian and New Zealand College of Radiologists (RANZCR) guidelines.
  • Colonic polyps: Adenomatous polyps carry malignant potential (adenomaโ€“carcinoma sequence); serrated polyps also require surveillance. Colonoscopic polypectomy and histology determine follow-up intervals per the National Health and Medical Research Council (NHMRC) guidelines.

Premalignant Conditions

Several benign conditions carry a recognised risk of malignant transformation and require surveillance:

Premalignant Condition Associated Malignancy Estimated Transformation Risk
Barrett oesophagus Oesophageal adenocarcinoma 0.5% per year
Colonic adenomatous polyps Colorectal carcinoma 2.5โ€“5% over 10โ€“15 years (villous > tubular)
Cervical intraepithelial neoplasia (CIN 2/3) Cervical squamous cell carcinoma 12โ€“30% if untreated over 10โ€“15 years
Actinic keratoses Cutaneous squamous cell carcinoma ~1% per lesion per year
Oral leukoplakia Oral squamous cell carcinoma 5โ€“17% (higher if dysplasia present)
Monoclonal gammopathy of undetermined significance (MGUS) Multiple myeloma ~1% per year
Myelodysplastic syndrome (MDS) Acute myeloid leukaemia 20โ€“30% (varies by subtype)
โ„น๏ธ
Key clinical point: The distinction between benign and malignant is not always binary. Some benign-appearing lesions harbour occult malignancy, and some "malignant" neoplasms behave indolently (e.g. low-grade prostate carcinoma). Histopathological assessment remains the gold standard for definitive classification.

Cancer in Children โ€” Red Flags

Childhood cancer is rare, with approximately 1,000 new diagnoses per year in children aged 0โ€“14 years in Australia. Despite its rarity, cancer is the leading cause of disease-related death in Australian children. The most common childhood cancers are leukaemia (particularly acute lymphoblastic leukaemia, ALL), central nervous system (CNS) tumours, and lymphomas. Early diagnosis improves outcomes, yet diagnostic delays of 1โ€“6 months are common because presenting symptoms are often non-specific and mimic common benign paediatric conditions.

Common Childhood Cancers in Australia

Cancer Type Proportion (%) Peak Age Key Clinical Features
Acute lymphoblastic leukaemia (ALL) ~30% 2โ€“5 years Pallor, bruising, bone pain, hepatosplenomegaly, recurrent infections
CNS tumours ~20% 3โ€“12 years (varies by type) Headache (especially morning), vomiting, ataxia, visual changes, personality change
Neuroblastoma ~8% <5 years Abdominal mass, periorbital ecchymoses, opsoclonus-myoclonus
Wilms tumour (nephroblastoma) ~6% 2โ€“5 years Painless abdominal mass, haematuria, hypertension
Lymphoma (Hodgkin & non-Hodgkin) ~10% 5โ€“15 years Persistent painless lymphadenopathy, B symptoms (fever, night sweats, weight loss)
Rhabdomyosarcoma ~5% <10 years Painless mass in head/neck, genitourinary, or extremity
Bone tumours (osteosarcoma, Ewing sarcoma) ~5% 10โ€“18 years Bone pain (often nocturnal), swelling, pathological fracture
Retinoblastoma ~3% <5 years Leukocoria (white pupillary reflex), strabismus

Red-Flag Symptoms in Children โ€” When to Investigate Urgently

๐Ÿšจ
Urgent referral warranted if any of the following are present: A child with persistent, unexplained symptoms from the list below should be investigated without delay. Do not reassure without assessment โ€” cancer in children is often mistaken for common benign conditions.
Investigate Promptly
Single Unexplained Symptom >2โ€“4 Weeks
Persistent unexplained fatigue, recurrent unexplained fevers (>38ยฐC for >2 weeks without source), unexplained weight loss (>5% body weight), new persistent limp not associated with injury, persistent bone or joint pain (especially nocturnal).
Setting: GP assessment within 1 week
Investigate Urgently
Suggestive Clinical Signs
Unexplained bruising or petechiae (especially non-dependent, non-traumatic), unexplained palpable mass (abdominal, testicular, limb), persistent painless lymphadenopathy (>2 cm, firm, non-tender, >4 weeks), proptosis or raccoon eyes, new squint or visual changes, morning vomiting ยฑ headache.
Setting: Same-week GP assessment + FBE/CRP/ESR + consider urgent paediatric referral
Same-Day Referral
Acute Concerning Presentations
Leukocoria (white pupillary reflex in a photograph), unexplained pancytopenia, suspected spinal cord compression, superior vena cava obstruction, acute stridor with mediastinal mass, testicular mass in a child.
Setting: Emergency department or direct paediatric oncology referral

Initial Investigations in Primary Care

When childhood cancer is suspected, the following initial investigations can be performed in general practice while arranging specialist referral:

Available Full blood examination (FBE) with film May reveal anaemia, thrombocytopenia, leucocytosis/leucopenia, blast cells. MBS Item 65070.
Available Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) Non-specific markers; markedly elevated ESR in lymphoma, leukaemia, Ewing sarcoma. MBS Item 65060.
Available Renal function tests, liver function tests, LDH, urate Elevated LDH and urate suggest high tumour burden (lymphoma, leukaemia). Tumour lysis syndrome risk assessment.
Essential Urine catecholamines (VMA/HVA) Screening for neuroblastoma โ€” elevated urinary vanillylmandelic acid (VMA) and homovanillic acid (HVA).
Referral CT / MRI / Ultrasound imaging Usually arranged by paediatric specialist or paediatric oncology centre. Accessible at all paediatric tertiary centres.
โš ๏ธ
Avoid diagnostic delay: Do not request a "watch and wait" approach beyond 2โ€“4 weeks for persistent unexplained symptoms in children. If clinical suspicion remains after initial normal investigations, refer to a paediatrician or paediatric oncologist. Normal blood tests do not exclude cancer in children โ€” CNS tumours and solid organ tumours often have normal haematological markers.

Clinical Manifestations & Paraneoplastic Syndromes

The clinical manifestations of malignant disease can be broadly categorised into: (1) local effects of the primary tumour, (2) regional and metastatic spread, (3) systemic constitutional symptoms, and (4) paraneoplastic syndromes. Recognition of these diverse presentations is essential for general practitioners, as paraneoplastic syndromes may be the first โ€” and sometimes only โ€” clinical clue to an occult malignancy.

Constitutional ("B") Symptoms

Constitutional symptoms associated with malignancy include:

  • Unexplained weight loss โ€” >5% body weight over 6 months without intentional dietary change
  • Unexplained fever โ€” particularly in haematological malignancies; Pel-Ebstein (cyclical) fever classically in Hodgkin lymphoma
  • Drenching night sweats โ€” soaking through pyjamas/bedding; characteristic of lymphoma
  • Fatigue โ€” cancer-related fatigue is disproportionate to activity level and not relieved by rest
  • Anorexia โ€” associated with cachexia in advanced disease

Paraneoplastic Syndromes โ€” Classification

Paraneoplastic syndromes are clinical manifestations that occur in association with malignancy but are not caused by direct tumour invasion, mass effect, or metastasis. They are mediated by tumour-secreted hormones, cytokines, or immune cross-reactivity and affect approximately 8โ€“15% of cancer patients. Recognition is critical as treatment of the underlying malignancy often improves the paraneoplastic syndrome.

Endocrine Paraneoplastic Syndromes

Syndrome Mechanism Associated Cancers Key Features
SIADH (Syndrome of Inappropriate ADH) Ectopic ADH/vasopressin production Small cell lung cancer (SCLC) โ€” most common; CNS tumours, head & neck cancers Hyponatraemia, euvolaemic fluid retention, serum osmolality <275 mOsm/kg, urine osmolality >100 mOsm/kg, clinical confusion/lethargy
Cushing Syndrome (ectopic ACTH) Ectopic ACTH production SCLC, carcinoid tumours, medullary thyroid carcinoma, phaeochromocytoma Rapid-onset hypokalaemic metabolic alkalosis, hyperglycaemia, proximal myopathy, skin thinning (may lack classic Cushingoid features due to rapid onset)
Hypercalcaemia of Malignancy PTHrP secretion (most common), osteolytic metastases, 1,25(OH)โ‚‚D production Squamous cell carcinoes (lung, head & neck), breast, renal, multiple myeloma, lymphoma "Stones, bones, groans, moans, psychiatric overtones" โ€” polyuria, constipation, confusion, bone pain, nausea. Corrected calcium >2.6 mmol/L
Hypoglycaemia (non-islet cell tumour) Ectopic insulin-like growth factor 2 (IGF-2) secretion Fibrosarcoma, hepatocellular carcinoma, retroperitoneal sarcoma Recurrent fasting hypoglycaemia with low insulin, C-peptide; suppressed ketones
Hypercalcaemia (humoral) PTHrP (parathyroid hormone-related peptide) Lung (squamous), renal, bladder, ovarian Suppress PTH; elevated PTHrP; treat with IV normal saline, bisphosphonates (zoledronic acid)

Neurological Paraneoplastic Syndromes

Syndrome Antibody Associated Cancers Clinical Features
Lambert-Eaton Myasthenic Syndrome (LEMS) Anti-VGCC (voltage-gated calcium channel) SCLC (~60% paraneoplastic) Proximal weakness, autonomic dysfunction, areflexia; improves with repeated use (post-exercise facilitation โ€” opposite of myasthenia gravis)
Subacute cerebellar degeneration Anti-Yo (breast/ovary), Anti-Hu (SCLC), Anti-Tr SCLC, breast, ovarian, Hodgkin lymphoma Rapidly progressive cerebellar ataxia, dysarthria, nystagmus; often severe and irreversible
Encephalomyelitis Anti-Hu (ANNA-1) SCLC Multifocal โ€” limbic encephalitis, sensory neuronopathy, autonomic dysfunction
Limbic encephalitis Anti-Ma2, Anti-NMDA-R, Anti-LGI1, Anti-CASPR2 Testicular germ cell (Ma2), SCLC, thymoma Short-term memory loss, seizures, psychiatric features, hyponatraemia
Sensory neuronopathy Anti-Hu SCLC Asymmetric sensory loss, pseudoathetosis, sensory ataxia; often painful

Dermatological Paraneoplastic Syndromes

Syndrome Associated Cancers Clinical Features
Dermatomyositis Ovarian, lung, colorectal, pancreatic, lymphoma Heliotrope rash, Gottron papules, proximal myopathy, elevated CK. New-onset dermatomyositis in adults >40 warrants cancer screen.
Acanthosis nigricans (malignant) Gastric adenocarcinoma (most common), other GI cancers Rapid-onset, extensive hyperpigmented velvety skin folds; may involve mucous membranes and palms (tripe palms)
Sweet syndrome (acute febrile neutrophilic dermatosis) Haematological malignancies (MDS, AML), solid tumours Painful erythematous plaques/nodules, fever, neutrophilia, pathergy
Dermatitis herpetiformis Lymphoma (increased risk associated with coeliac disease) Intensely pruritic vesicles on extensor surfaces; IgA deposits at dermal papillae
Leser-Trรฉlat sign GI adenocarcinoma (colorectal, gastric) Sudden eruption of multiple seborrhoeic keratoses with pruritus

Haematological Paraneoplastic Syndromes

  • Deep venous thrombosis / pulmonary embolism โ€” Trousseau syndrome (migratory superficial thrombophlebitis) is classically associated with pancreatic cancer but occurs with many malignancies. Malignancy should be considered in patients <40 years with unprovoked VTE.
  • Disseminated intravascular coagulation (DIC) โ€” particularly in acute promyelocytic leukaemia (APL), mucin-secreting adenocarcinomas.
  • Autoimmune haemolytic anaemia (AIHA) โ€” chronic lymphocytic leukaemia (CLL), lymphomas.
  • Thrombotic microangiopathy (TMA) โ€” GI cancers, breast cancer, SCLC.
  • Non-bacterial thrombotic endocarditis (marantic endocarditis) โ€” mucin-secreting adenocarcinomas.

Other Notable Paraneoplastic Manifestations

  • Hypertrophic osteoarthropathy (HOA) โ€” digital clubbing, periostitis, arthropathy; associated with lung cancer (especially non-small cell). May resolve with tumour resection.
  • Nephrotic syndrome โ€” membranous nephropathy (solid tumours), minimal change disease (Hodgkin lymphoma).
  • Polymyositis โ€” similar malignancy association as dermatomyositis.
  • Cancer-associated retinopathy โ€” anti-recoverin antibodies; SCLC, gynaecological cancers.
โš ๏ธ
When to suspect a paraneoplastic syndrome: Any new-onset endocrine abnormality (especially SIADH or Cushing syndrome), neurological syndrome (especially LEMS, cerebellar ataxia, or limbic encephalitis), or dermatological condition (especially dermatomyositis in adults >40) warrants a screen for occult malignancy. Age-appropriate cancer screening should be complemented by CT chest/abdomen/pelvis, tumour markers, and relevant autoantibodies.

Investigations for Paraneoplastic Syndromes

Available Serum paraneoplastic antibodies (ANNA-1/anti-Hu, anti-Yo, anti-VGCC, anti-Ma2, anti-NMDA-R, anti-LGI1, anti-CASPR2, anti-recoverin) Sent to specialised immunopathology laboratories. In Australia, available through major teaching hospital immunopathology labs. Results take 2โ€“4 weeks. MBS Item 71138.
Available CT chest, abdomen, pelvis with IV contrast First-line imaging for occult malignancy. MBS Item 56800 (CT chest) / 56802 (CT abdomen/pelvis). Bulk-billed at most radiology practices.
Available FDG-PET/CT Superior sensitivity for occult malignancy when CT is negative. Available at all major metropolitan PET centres. MBS Item 61355 (requires Medicare eligibility criteria to be met โ€” authority required for investigation of paraneoplastic syndrome).
Referral MRI brain and spinal cord For neurological paraneoplastic syndromes. Arranged by neurologist or oncologist.
Available Tumour markers (CEA, CA-125, CA 19-9, AFP, ฮฒ-hCG, PSA, NSE, chromogranin A) Low specificity in isolation; useful in context of known/suspected malignancy. MBS Item 66678 (single marker) / 66679 (panel).

Occupational Causes of Cancer

Occupational cancer accounts for an estimated 3.2โ€“6.5% of all cancers in Australia. The International Agency for Research on Cancer (IARC) classifies carcinogens into Group 1 (definite), Group 2A (probable), and Group 2B (possible) carcinogens. In Australia, Safe Work Australia and state-based work health and safety (WHS) regulators maintain frameworks for minimising carcinogen exposure. General practitioners play a vital role in recognising occupational exposures, documenting them in the medical record, and facilitating workers' compensation claims.

Major Occupational Carcinogens in Australia

Carcinogen IARC Group Associated Malignancies Common Australian Industries/Exposures Latency Period
Asbestos (all forms) 1 Mesothelioma, lung cancer, laryngeal cancer, ovarian cancer Building trades, mining (Wittenoom), insulation, shipbuilding, brake mechanics, demolition 20โ€“50 years (mesothelioma); 15โ€“35 years (lung cancer)
Benzene 1 Acute myeloid leukaemia (AML), non-Hodgkin lymphoma, multiple myeloma Petroleum refining, chemical manufacturing, petrol station workers, painters 1โ€“30 years (AML shorter latency)
Crystalline silica 1 Lung cancer, silicosis (progressive massive fibrosis), renal cancer Mining, quarrying, tunnelling, sandblasting, engineered stone benchtop fabrication (accelerated silicosis), construction, pottery 10โ€“30 years; accelerated silicosis can develop within 5โ€“10 years in engineered stone workers
Solar ultraviolet radiation (UVR) 1 Cutaneous melanoma, squamous cell carcinoma, basal cell carcinoma Outdoor workers โ€” construction, agriculture, mining, fisheries, military, sport & recreation 10โ€“40 years
Wood dust 1 Nasopharyngeal carcinoma, sinonasal adenocarcinoma Furniture making, carpentry, sawmill operations, cabinet making 20โ€“40 years
Arsenic & inorganic arsenic compounds 1 Lung cancer, skin cancer (squamous cell), bladder cancer, liver angiosarcoma Copper smelting, pesticide manufacturing, wood preservation (CCA-treated timber), mining 5โ€“30 years
Cadmium & cadmium compounds 1 Lung cancer, prostate cancer Battery manufacturing, welding (cadmium-coated metals), electroplating, pigment manufacture 10โ€“30 years
Chromium VI (hexavalent) 1 Lung cancer, nasal & paranasal sinus cancer Chrome plating, stainless steel welding, leather tanning, chromate pigment production 5โ€“20 years
Radon 1 Lung cancer (second leading cause after smoking) Underground mining (particularly uranium), some building materials, basement/ground-floor occupations in high-radon areas 5โ€“25 years
Formaldehyde 1 Nasopharyngeal carcinoma, leukaemia (limited evidence) Pathology/anatomy labs, mortuaries, embalming, resin manufacturing, textile finishing 10โ€“20 years
Welding fumes 1 Lung cancer Construction, manufacturing, shipbuilding, automotive trades 10โ€“30 years

Asbestos-Related Disease โ€” A Major Australian Concern

Australia was historically one of the highest per-capita users of asbestos, with widespread use from the 1940s to the mid-1980s. All forms of asbestos were prohibited from import and use in Australia in December 2003 (Work Health and Safety Regulations). However, legacy asbestos remains in an estimated one-third of Australian homes and many commercial buildings.

โš ๏ธ
Asbestos-related mesothelioma: Australia has one of the highest per-capita rates of malignant mesothelioma globally, with approximately 700โ€“800 new cases per year. The median latency from first exposure to diagnosis is 30โ€“40 years. The median survival from diagnosis is 12โ€“18 months. Any patient with a history of asbestos exposure who develops pleural effusion, pleural thickening, or chest wall pain should be urgently investigated. Asbestos-related diseases are compensable under state-based workers' compensation and dust diseases legislation.

Silica and Accelerated Silicosis

Since 2018, Australia has experienced a concerning emergence of accelerated silicosis among workers fabricating engineered stone (e.g. Caesarstoneยฎ, Essastoneยฎ) kitchen and bathroom benchtops. This has been termed a "new asbestos" by some commentators. In 2024, Safe Work Australia recommended a ban on engineered stone products, which was implemented nationally from 1 July 2024. Workers with crystalline silica exposure are at increased risk of both silicosis and lung cancer (with a synergistic effect when combined with smoking).

๐Ÿšจ
Mandatory notification: Silicosis (and all pneumoconioses) is a notifiable occupational disease in all Australian states and territories. Practitioners must notify the relevant state or territory work health and safety authority upon diagnosis.

GP Approach to Suspected Occupational Cancer

1
Detailed Occupational History
Document all occupations from first job onwards, including duration, specific exposures, and use of personal protective equipment (PPE). Use the WorkCover or Safe Work Australia exposure history template.
2
Document in Medical Record
Record occupational exposures clearly in the patient's problem list. This is medicolegally essential for future workers' compensation claims, even if the patient is not yet symptomatic.
3
Screening & Surveillance
For workers with significant prior asbestos or silica exposure: low-dose CT chest may be appropriate (discuss with respiratory physician). Note: Medicare does not currently fund routine screening CT for occupational exposure alone โ€” referral to an occupational physician or respiratory physician is recommended.
4
Workers' Compensation Referral
Refer to the relevant state/territory dust diseases authority or workers' compensation insurer. In NSW: Dust Diseases Authority; in Victoria: WorkSafe Victoria; in Queensland: WorkCover Queensland. Provide a detailed medical report including exposure history.

Preventive Strategies โ€” The GP Role

  • Sun safety counselling โ€” The Cancer Council Australia recommends Slip, Slop, Slap, Seek, Slide for all outdoor workers. Workplace sun protection policies are mandated under WHS law.
  • Smoking cessation โ€” Synergistic carcinogenic effect with occupational exposures (asbestos + smoking โ†’ 50-fold increased lung cancer risk; silica + smoking โ†’ 10-fold increased risk).
  • Occupational health referrals โ€” For patients in high-risk industries, recommend pre-employment health assessments and periodic surveillance.
  • Awareness of emerging risks โ€” PFAS ("forever chemicals") exposure is an area of active investigation; residents near military bases and airports with PFAS-contaminated water may require monitoring.

Investigations & Diagnostic Approach in General Practice

When malignancy is suspected in general practice, the investigation approach should be systematic and guided by the clinical presentation. The goal is to initiate the diagnostic pathway without delay while arranging specialist referral.

General Investigations โ€” First-Line (GP-Accessible)

Essential Full blood examination (FBE) with blood film Screen for haematological malignancy (abnormal white cells, cytopenias), iron deficiency anaemia (GI malignancy), or reactive changes. MBS Item 65070.
Essential Comprehensive metabolic panel (U&Es, LFTs, calcium, phosphate, glucose, LDH, urate) LDH is a non-specific marker of tumour burden. Hypercalcaemia may indicate bony metastases or humoral hypercalcaemia. Liver function derangement may indicate hepatic metastases. MBS Item 66515.
Available ESR and CRP Non-specific inflammatory markers; useful as adjuncts. Markedly elevated ESR (>50 mm/hr) in an older adult should prompt consideration of malignancy, myeloma, or giant cell arteritis. MBS Item 65060.
Available Faecal immunochemical test (FIT) โ€” quantitative For suspected colorectal cancer. The NBCSP provides free FIT kits to Australians aged 45โ€“74. GP-requested FIT is available via MBS Item 66771. Quantitative FIT โ‰ฅ10 ยตg Hb/g faeces warrants colonoscopy referral.
Available Serum protein electrophoresis (SPE) and serum free light chains Screening for myeloma, Waldenstrรถm macroglobulinaemia. MBS Item 66575 (SPE) / 66576 (free light chains).
Available Prostate-specific antigen (PSA) For suspected prostate cancer (after informed shared decision-making per Prostate Cancer Foundation of Australia guidelines). MBS Item 66658.
Available Tumour markers (CEA, CA-125, CA 19-9, AFP, ฮฒ-hCG, NSE) Limited role in initial screening; useful for monitoring known malignancy. Do not use in isolation to diagnose cancer. MBS Item 66678/66679.
Available Urinalysis (microscopy, culture, cytology) Persistent microscopic haematuria in adults >40 warrants urological investigation to exclude bladder/renal malignancy. MBS Item 69310.

Imaging โ€” GP-Initiated

Available Chest X-ray (PA and lateral) First-line for suspected lung cancer, mediastinal mass, or pleural effusion. MBS Item 58803. Abnormal findings warrant CT chest.
Available Ultrasound โ€” breast, thyroid, testis, abdomen/pelvis, soft tissue GP-requested ultrasound is widely accessible. Particularly useful for palpable breast lumps (MBS Item 55056), thyroid nodules (MBS Item 55059), testicular masses (MBS Item 55060). Bulk-billed at most practices.
Referral CT with IV contrast GP-requested CT is available but generally initiated after specialist review for cancer staging. CT chest (MBS Item 56800), CT abdomen/pelvis (MBS Item 56802).
Referral MRI Best for soft tissue characterisation, CNS tumours, bone marrow assessment. Usually specialist-arranged. MBS Item 63001 (brain) / 63007 (spine).
Specialist FDG-PET/CT For staging and detection of occult primary malignancy. Authority-required MBS Item 61355. Available at major metropolitan centres (approx. 40 sites nationally).

The "Two-Week Wait" Principle

โœ…
Best practice: When clinical suspicion of cancer is high, the patient should be seen by an appropriate specialist within 2 weeks. This is not a formalised "two-week wait" pathway as in the NHS, but Australian cancer guidelines recommend urgent referral for suspected malignancy. Most metropolitan cancer centres accept urgent referrals for suspected cancer โ€” the referral letter should clearly state "suspected malignancy" with supporting clinical features.

Special Populations

๐Ÿคฐ

Pregnancy

Incidence: Approximately 1 in 1,000 pregnancies are complicated by cancer. Most common: breast cancer, melanoma, cervical cancer, thyroid cancer, haematological malignancies.
Diagnostic delay risk: Cancer symptoms (fatigue, nausea, breast changes) may be attributed to pregnancy, delaying diagnosis by 2โ€“6 months on average.
Imaging safety: Ultrasound and MRI (without gadolinium) are safe. CT involves ionising radiation โ€” use only when benefit clearly outweighs risk, and discuss with patient.
Treatment considerations: Surgery is safe in all trimesters. Chemotherapy is generally contraindicated in the first trimester (organogenesis); from the second trimester, many agents can be used. Platinum-based chemotherapy, anthracyclines, and taxanes have the most safety data.
Referral pathway: All pregnant women with suspected malignancy should be referred to a centre with experience in managing cancer in pregnancy (maternalโ€“fetal medicine + oncology MDT). The decision to treat, delay, or terminate pregnancy is deeply personal and requires multidisciplinary support.
๐Ÿ‘ถ

Paediatrics

Epidemiology: Approximately 1,000 new cases per year in Australia (0โ€“14 years). 5-year survival >85% overall. ALL is the most common childhood cancer (~30%).
Key concern: Diagnostic delay is common (mean 4โ€“6 weeks). Parents and GPs may attribute symptoms to benign conditions. Maintain a high index of suspicion for persistent unexplained symptoms (see Childhood Cancer section).
Referral pathway: All children with suspected cancer should be referred to a Children's Cancer Centre (e.g. Kids Cancer Centre at Sydney Children's Hospital, Royal Children's Hospital Melbourne, Queensland Children's Hospital).
Long-term follow-up: Childhood cancer survivors require lifelong surveillance for late effects of treatment (cardiomyopathy, secondary malignancies, endocrine dysfunction, neurocognitive effects). The Australian Childhood Cancer Survivor Study provides guidelines.
๐Ÿ‘ด

Elderly

Cancer burden: More than 60% of cancers in Australia occur in people aged โ‰ฅ65 years. The median age at cancer diagnosis is 69 years.
Geriatric assessment: Functional status (ECOG, Karnofsky), comorbidity burden, polypharmacy, cognitive status, nutritional status, and social supports should be assessed using validated geriatric oncology tools (e.g. G8 screening tool, VES-13).
Treatment considerations: Treatment decisions should be based on biological age (fitness) rather than chronological age. Dose modifications are often required. Shared decision-making is essential, incorporating patient goals of care.
Palliative care integration: Early integration of palliative care improves quality of life and may improve survival. Refer to palliative care services when life expectancy is <12 months or when symptom burden is high.
๐Ÿซ˜

Renal Impairment

Considerations: Many chemotherapy agents are nephrotoxic (cisplatin, methotrexate, ifosfamide) or renally cleared and require dose adjustment. eGFR should be calculated at baseline and before each cycle (CKD-EPI formula preferred).
Key agents requiring dose adjustment: Carboplatin (Calvert formula using GFR), methotrexate (contraindicated if CrCl <60 mL/min), capecitabine, gemcitabine, etoposide. Consult eviQ (cancer treatment protocols) for renal dose adjustments.
Tumour lysis syndrome risk: Higher risk in patients with pre-existing renal impairment and high tumour burden (lymphoma, leukaemia). Aggressive IV hydration and rasburicase (if urate >0.47 mmol/L) are required prophylactically.
๐Ÿ›ก๏ธ

Immunocompromised

HIV-associated malignancies: AIDS-defining cancers (Kaposi sarcoma, primary CNS lymphoma, invasive cervical cancer) and non-AIDS-defining cancers (Hodgkin lymphoma, anal cancer, hepatocellular carcinoma, lung cancer) have increased incidence in people living with HIV. Effective antiretroviral therapy (ART) reduces but does not eliminate risk.
Transplant recipients: Solid organ transplant recipients have 2โ€“4 times higher overall cancer risk. Post-transplant lymphoproliferative disorder (PTLD, often EBV-associated), skin cancers (squamous cell carcinoma risk 65โ€“250 times higher), and Kaposi sarcoma are particularly increased.
Immunosuppressive therapy: Patients on long-term immunosuppressants (azathioprine, mycophenolate, cyclosporine, biologics) require regular skin checks, cervical screening, and vigilance for lymphoma and skin cancers.
๐Ÿซ

Hepatic Impairment

Considerations: Hepatic impairment affects drug metabolism (phase I and II reactions). Child-Pugh classification guides dose adjustments. Many agents are hepatotoxic (methotrexate, 5-FU, tamoxifen, TKIs).
Hepatocellular carcinoma (HCC): Surveillance with 6-monthly ultrasound ยฑ AFP recommended for patients with cirrhosis (any cause), chronic hepatitis B (even without cirrhosis in high-risk groups), and chronic hepatitis C with advanced fibrosis.
Liver metastases: Metastatic liver disease is more common than primary liver malignancy. Colorectal cancer liver metastases may be amenable to surgical resection (oligometastatic disease) โ€” refer to HPB surgery MDT.

Aboriginal and Torres Strait Islander Health Considerations

Aboriginal and Torres Strait Islander Health

Cancer is a significant and growing health concern for Aboriginal and Torres Strait Islander Australians. Despite lower overall incidence of some cancers compared to non-Indigenous Australians, Aboriginal and Torres Strait Islander peoples experience substantially worse outcomes across the cancer continuum โ€” from later-stage diagnosis to lower treatment rates and higher mortality.

Key Statistics (AIHW 2024)

  • Aboriginal and Torres Strait Islander Australians have a 1.4-fold higher overall cancer incidence and 1.8-fold higher cancer mortality compared with non-Indigenous Australians.
  • Cancer is the second leading cause of death among Aboriginal and Torres Strait Islander peoples (after cardiovascular disease).
  • Five-year survival is 10โ€“15% lower for Aboriginal and Torres Strait Islander cancer patients compared to non-Indigenous patients across most cancer types.
  • Lung cancer, liver cancer, cervical cancer, and head and neck cancers are disproportionately more common in Aboriginal and Torres Strait Islander populations.
  • Cervical cancer incidence is 3โ€“4 times higher among Aboriginal and Torres Strait Islander women, partly due to lower participation in the National Cervical Screening Program.
  • Liver cancer (hepatocellular carcinoma) incidence is 3 times higher, driven by higher prevalence of chronic hepatitis B and higher rates of alcohol-related liver disease.
Late-stage presentation
Aboriginal and Torres Strait Islander patients are more likely to present with advanced-stage disease, reducing treatment options and survival. This reflects barriers to early detection, screening participation, and timely access to investigation.
Access to specialist care
Geographic remoteness is a major barrier. Many Aboriginal and Torres Strait Islander communities are in remote or very remote areas with limited access to oncology, surgical, and radiation oncology services. Treatment often requires relocation to metropolitan centres, causing significant family and cultural disruption.
Screening participation
Participation in the National Bowel Cancer Screening Program and National Cervical Screening Program is lower among Aboriginal and Torres Strait Islander peoples. Culturally safe screening programs delivered through Aboriginal Community Controlled Health Services (ACCHS) show improved uptake.
Cultural safety in treatment
Cancer treatment can be culturally isolating for Aboriginal and Torres Strait Islander patients in mainstream health services. Lack of Indigenous liaison officers, culturally inappropriate communication about diagnosis and prognosis, and "Sorry Business" obligations (cultural mourning practices that may temporarily take priority over treatment appointments) must be respected and accommodated.
Tobacco and alcohol
Tobacco smoking prevalence is approximately 2.5 times higher among Aboriginal and Torres Strait Islander adults compared to non-Indigenous adults, contributing to higher rates of lung, head and neck, and oesophageal cancers. Culturally tailored smoking cessation programs (e.g. Tackling Indigenous Smoking program) are essential.
Hepatitis B
Chronic hepatitis B prevalence is 3โ€“5 times higher in Aboriginal and Torres Strait Islander communities. Universal hepatitis B vaccination (included in the National Immunisation Program since 2000) will reduce future liver cancer burden, but current adult cohorts require screening, surveillance, and antiviral treatment per ASHM guidelines.

Recommended Actions for GPs

  • Proactive screening: Ensure all Aboriginal and Torres Strait Islander patients are up to date with bowel cancer screening (FIT), cervical screening, and breast screening (BreastScreen Australia). Opportunistic screening during health assessments (MBS Item 715) is recommended.
  • Hepatitis B screening: Offer hepatitis B serology to all Aboriginal and Torres Strait Islander patients who have not been screened. Link to antiviral treatment and HCC surveillance if chronic HBV is identified.
  • Culturally safe communication: Use plain language, involve family members and Aboriginal Health Workers/Accredited Practitioners in consultations, and allow adequate time for discussion. The Cancer Council Australia provides culturally appropriate cancer information resources.
  • Care coordination: Partner with local Aboriginal Community Controlled Health Services (ACCHS) for shared care. Identify Indigenous liaison officers at referral cancer centres. The McGrath Foundation and Cancer Council provide specialist breast care nurses with experience in Aboriginal and Torres Strait Islander health.
  • Smoking cessation: Prioritise culturally tailored smoking cessation interventions. Nicotine replacement therapy (NRT) is PBS-listed and accessible. Refer to the Quitline (13 7848) and state-based Tackling Indigenous Smoking services.
  • Advance care planning: Discuss advance care planning sensitively, respecting cultural beliefs about death, dying, and "Sorry Business." Use the End of Life Law for Clinicians (QUT) resources and Palliative Care Australia guidelines.
โ„น๏ธ
Resources: Cancer Council Australia โ€” Aboriginal and Torres Strait Islander cancer information (cancer.org.au); National Aboriginal Community Controlled Health Organisation (NACCHO); RHDAustralia (rhdaustralia.com.au); Australian Indigenous HealthInfoNet (healthinfonet.ecu.edu.au).

๐Ÿ“š References

  1. 1. Australian Institute of Health and Welfare (AIHW). Cancer in Australia 2024. AIHW; Canberra: 2024. Available from: https://www.aihw.gov.au/reports/cancer/cancer-in-australia
  2. 2. Australian Institute of Health and Welfare (AIHW). Aboriginal and Torres Strait Islander Health Performance Framework: Cancer. AIHW; Canberra: 2023.
  3. 3. Cancer Council Australia. Clinical Practice Guidelines for the Management of Melanoma in Australia and New Zealand. Cancer Council Australia; Sydney: 2018 (updated 2023).
  4. 4. National Health and Medical Research Council (NHMRC). Clinical Practice Guidelines for the Prevention, Early Detection and Management of Colorectal Cancer. 3rd ed. Cancer Council Australia; Sydney: 2017.
  5. 5. Royal Australian College of General Practitioners (RACGP). Guidelines for Preventive Activities in General Practice (Red Book). 9th ed. RACGP; Melbourne: 2018 (updated 2023).
  6. 6. Darnell RB, Posner JB. Paraneoplastic syndromes involving the nervous system. N Engl J Med. 2003;349(16):1543โ€“1554.
  7. 7. Pelosof LC, Gerber DE. Paraneoplastic syndromes: an approach to diagnosis and treatment. Mayo Clin Proc. 2010;85(9):838โ€“854.
  8. 8. Safe Work Australia. Model Code of Practice: Managing the Risks of Hazardous Chemicals in the Workplace. Safe Work Australia; Canberra: 2023.
  9. 9. International Agency for Research on Cancer (IARC). IARC Monographs on the Identification of Carcinogenic Hazards to Humans. Volumes 1โ€“132. Lyon: IARC; 2024.
  10. 10. Occupational Health and Safety Unit (Safe Work Australia). Prohibition on the Use of Enginestone โ€” Decision Regulation Impact Statement. Safe Work Australia; Canberra: 2024.
  11. 11. Magnanti BL, et al. Occupational cancer in Australia. Aust N Z J Public Health. 2023;47(2):100034.
  12. 12. Australian Childhood Cancer Survivor Study. Long-Term Follow-Up Guidelines for Survivors of Childhood, Adolescent and Young Adult Cancers. Children's Cancer Institute; Sydney: 2023.
  13. 13. Palliative Care Australia. National Palliative Care Standards. 5th ed. Palliative Care Australia; Canberra: 2018.
  14. 14. Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine (ASHM). Recommendations for the Management of Hepatitis B Virus Infection in Aboriginal and Torres Strait Islander Peoples. ASHM; Sydney: 2022.
  15. 15. Zalcberg J, et al. eviQ Cancer Treatments Online โ€” Cancer Institute NSW. Available from: https://www.eviq.org.au. Accessed 2024.
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3โ€“4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

๐Ÿ“š References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924โ€“939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736โ€“745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583โ€“1599.
  5. 5. Smolen JS, Landewรฉ RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3โ€“18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487โ€“1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing โ€” misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Associationโ€“European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771โ€“1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFฮฑ blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155โ€“158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).
for PBS-listed medicines at participating pharmacies.
Cultural safety
Engagement with Aboriginal Community Controlled Health Organisations (ACCHOs) is essential. Cultural safety training for non-Indigenous clinicians, use of Aboriginal Health Workers and Liaison Officers, and incorporation of traditional healing practices alongside Western medicine improve treatment adherence and outcomes. Avoidance of eye contact, respect for gender-sensitive examination practices, and understanding of sorry business protocols are critical elements of culturally safe care.
Medication adherence
Complex DMARD regimens with frequent monitoring requirements present adherence challenges. Long-acting depot injections (e.g., methotrexate SC) may improve adherence compared to oral regimens. Community pharmacy partnerships through the Indigenous Pharmacy Programmes improve medication management.
Specific conditions
Rheumatic heart disease (RHD) requires secondary prophylaxis with benzathine penicillin G (BPG) 1.2 MU IM every 3โ€“4 weeks for a minimum of 10 years or until age 21 (whichever is longer). RHD registers (e.g., NT RHD Register) facilitate recall and follow-up. The Australian RHD Endgame Strategy targets elimination by 2031.
Referral pathways
Referral through ACCHOs and Aboriginal Hospital Liaison Officers (AHLOs) improves engagement. The Specialist Outreach Assistance Programme provides funded specialist visits to remote communities. NT, WA, and QLD have specific rheumatology outreach programmes targeting Indigenous communities.

๐Ÿ“š References

  1. 1. Australian Institute of Health and Welfare (AIHW). Autoimmune disease in Australia. Cat. no. PHE 312. Canberra: AIHW; 2023.
  2. 2. Fraenkel L, Bathon JM, England BR, et al. 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care Res. 2021;73(7):924โ€“939.
  3. 3. Fanouriakis A, Kostopoulou M, Alber K, et al. 2019 update of the EULAR recommendations for the management of systemic lupus erythematosus. Ann Rheum Dis. 2019;78(6):736โ€“745.
  4. 4. Chung SA, Langford CA, Maz M, et al. 2021 American College of Rheumatology/Vasculitis Foundation guideline for the management of antineutrophil cytoplasmic antibody-associated vasculitis. Arthritis Care Res. 2021;73(11):1583โ€“1599.
  5. 5. Smolen JS, Landewรฉ RBM, Bijlsma JWJ, et al. EULAR recommendations for the management of rheumatoid arthritis with synthetic and biological disease-modifying antirheumatic drugs: 2022 update. Ann Rheum Dis. 2023;82(1):3โ€“18.
  6. 6. Australian Technical Advisory Group on Immunisation (ATAGI). Australian Immunisation Handbook. Australian Government Department of Health; 2024. Available from: immunisationhandbook.health.gov.au.
  7. 7. Rheumatic Heart Disease Australia (RHDAustralia). The 2020 Australian guideline for prevention, diagnosis, and management of acute rheumatic fever and rheumatic heart disease. 3rd ed. Darwin: Menzies School of Health Research; 2020.
  8. 8. Pharmaceutical Benefits Scheme (PBS). PBS Schedule. Australian Government Department of Health. Available from: pbs.gov.au. Accessed 2024.
  9. 9. Agarwal S, Cunnington J, Nossent J. Autoimmune disease in Indigenous Australians: a systematic review. Int J Rheum Dis. 2021;24(12):1487โ€“1498.
  10. 10. Pisetsky DS. Antinuclear antibody testing โ€” misunderstood or misused? Clin Immunol. 2023;255:109717.
  11. 11. Bertsias GK, Tektonidou M, Amoura Z, et al. Joint European League Against Rheumatism and European Renal Associationโ€“European Dialysis and Transplant Association (EULAR/ERA-EDTA) recommendations for the management of adult and paediatric lupus nephritis. Ann Rheum Dis. 2012;71(11):1771โ€“1782.
  12. 12. Ledingham J, Deighton C; British Society for Rheumatology Standards, Audit and Guidelines Working Group. Update on the British Society for Rheumatology guidelines for prescribing TNFฮฑ blockers in adults with rheumatoid arthritis. Rheumatology. 2005;44(2):155โ€“158.
  13. 13. National Health and Medical Research Council (NHMRC). National statement on ethical conduct in human research. Canberra: NHMRC; 2023 (updated).