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Background: Gastrointestinal stromal tumours (GISTs) are the most common mesenchymal tumours of the gastrointestinal tract. The New Zealand (NZ) population incidence has not previously been documented nor has the potential effect of ethnicity been reviewed. We furthermore wanted to assess the difference between those undergoing a wedge resection versus a more extensive operation which we hypothesised would correlate with recurrence and mortality. Methods: All patients (n = 103) with a GIST diagnosed and treated at Te Whatu Ora Waitematā (Auckland, New Zealand) between 2012 and 2021 are presented. Patient demographics, method of GIST detection, management approach, index surgery, histological features, use of adjuvant and neoadjuvant imatinib, follow‐up, recurrence and mortality rates were analysed. Results: This paper reports the largest NZ GIST cohort to date and estimates an incidence of 17 cases per million per year. Eighty‐four patients underwent surgical resection, 58 received a wedge resection and 17 received a more extensive operation. Five‐year disease‐free survival rates were 100% in the low/very low risk, 90% in the intermediate and 59% in the high risk groups as determined by the modified NIH criteria. Our overall 5‐year GIST‐specific survival rate was 83%; it was 91% in those who underwent a wedge resection and 60% in the extensive operation group. There is evidence that Māori have higher rates of GIST recurrence compared to non‐Māori and are more likely to require an extensive surgical resection. [ABSTRACT FROM AUTHOR]

Introduction: New Zealand has a population of only 5.5 million meaning that for many surgical procedures the country qualifies as a "low‐volume center." However, the health system is well developed and required to provide complex surgical procedures that benchmark internationally against comparable countries. This investigation was undertaken to review regional variation and volumes of complex resection and palliative upper gastrointestinal (UGI) surgical procedures within New Zealand. Methods: Data pertaining to patients undergoing complex resectional UGI procedures (esophagectomy, gastrectomy, pancreatectomy, and hepatectomies) and palliative UGI procedures (esophageal stenting, enteroenterostomy, biliary enteric anastomosis, and liver ablation) in a New Zealand hospital between January 1, 2000 and December 31, 2019 were obtained from the National Minimum Dataset. Results: New Zealand is a low‐volume center for UGI surgery (229 hepatectomies, 250 gastrectomies, 126 pancreatectomies, and 74 esophagectomies annually). Over 80% of patients undergoing hepatic resection/ablation, gastrectomy, esophagectomy, and pancreatectomy are treated in one of the six national cancer centers (Auckland, Waikato, Mid‐Central, Capital Coast, Canterbury, or Southern). There is evidence of the decreasing frequency of these procedures in small centers with increasing frequency in large centers suggesting that some regionalization is occurring. Palliative procedures were more widely performed. Indigenous Māori were less likely to be treated in a nationally designated cancer center than non‐Māori. Conclusions: The challenge for New Zealand and similarly sized countries is to develop and implement a system that optimizes the skills and pathways that come from a frequent performance of complex surgery while maintaining system resilience and ensuring equitable access for all patients. [ABSTRACT FROM AUTHOR]

Background: An increasing number of older patients are undergoing emergency laparotomy (EL). Frailty is thought to contribute to adverse outcomes in this group. The best method to assess frailty and impacts on long‐term mortality and other important functional outcomes for older EL patients have not been fully explored. Methods: A prospective multicenter study of older EL patients was conducted across four hospital sites in New Zealand from August 2017 to September 2022. The Clinical Frailty Scale (CFS) was used to measure frailty—defined as a CFS of ≥5. Primary outcomes were 30‐day and one‐year mortality. Secondary outcomes were postoperative morbidity, admission for rehabilitation, and increased care level on discharge. A multivariate logistic regression analysis was conducted, adjusting for age, sex, and ethnicity. Results: A total of 629 participants were included. Frailty prevalence was 14.6%. Frail participants demonstrated higher 30‐day and 1‐year mortality—20.7% and 39.1%. Following adjustment, frailty was directly associated with a significantly increased risk of short‐ and long‐term mortality (30‐day aRR 2.6, 95% CI 1.5, 4.3, p = <0.001, 1‐year aRR 2.0, 95% CI 1.5, 2.8, p < 0.001). Frailty was correlated with a 2‐fold increased risk of admission for rehabilitation and propensity of being discharged to an increased level of care, complications, and readmission within 30 days. Conclusion: Frailty was associated with increased risk of postoperative mortality up to 1‐year and other functional outcomes for older patients undergoing EL. Identification of frailty in older EL patients aids in patient‐centered decision‐making, which may lead to improvement in outcomes. [ABSTRACT FROM AUTHOR]

Background: The 'weekend effect' is the term given to the observed discrepancy regarding patient care and outcomes on weekends compared to weekdays. This study aimed to determine whether the weekend effect exists within Aotearoa New Zealand (AoNZ) for patients undergoing emergency laparotomy (EL), given recent advances in management of EL patients. Methods: A cohort study was conducted across five hospitals, comparing the outcomes of weekend and weekday acute EL. A propensity‐score matched analysis was used to remove potential confounding patient characteristics. Results: Of the 487 patients included, 132 received EL over the weekend. There was no statistically significant difference between patients undergoing EL over the weekend compared to weekdays. Mortality rates were comparable between the weekday and weekend cohorts (P = 0.464). Conclusions: These results suggest that modern perioperative care practice in New Zealand obviates the 'weekend' effect. [ABSTRACT FROM AUTHOR]

The number of new cases of cancer is increasing each year, and rates of diabetes mellitus are also increasing dramatically over time. It is not an unusual occurrence for an individual to have both cancer and diabetes at the same time, given they are both individually common, and that one condition can increase the risk of the other. In this manuscript, we use national-level diabetes (Virtual Diabetes Register) and cancer (New Zealand Cancer Registry) data on nearly five million individuals over 44 million person-years of follow-up to examine the occurrence of cancer amongst a national prevalent cohort of patients with diabetes. We completed this analysis separately by cancer for the 24 most commonly diagnosed cancers in Aotearoa New Zealand, and then compared the occurrence of cancer among those with diabetes to those without diabetes. We found that the rate of cancer was highest amongst those with diabetes for 21 of the 24 most common cancers diagnosed over our study period, with excess risk among those with diabetes ranging between 11% (non-Hodgkin's lymphoma) and 236% (liver cancer). The cancers with the greatest difference in incidence between those with diabetes and those without diabetes tended to be within the endocrine or gastrointestinal system, and/or had a strong relationship with obesity. However, in an absolute sense, due to the volume of breast, colorectal and lung cancers, prevention of the more modest excess cancer risk among those with diabetes (16%, 22% and 48%, respectively) would lead to a substantial overall reduction in the total burden of cancer in the population. Our findings reinforce the fact that diabetes prevention activities are also cancer prevention activities, and must therefore be prioritised and resourced in tandem. [ABSTRACT FROM AUTHOR]

In New Zealand, there are known disparities between the Indigenous Māori and the majority non-Indigenous European populations in access to cancer treatment, with resulting disparities in cancer survival. There is international evidence of ethnic disparities in the distance travelled to access cancer treatment; and as such, the aim of this paper was to examine the distance and time travelled to access surgical care between Māori and European liver and stomach cancer patients. We used national-level data and Geographic Information Systems (GIS) analysis to describe the distance travelled by patients to receive their first primary surgery for liver or stomach cancer, as well as the estimated time to travel this distance by road, and the surgical volume of hospitals performing these procedures. All cases of liver (ICD-10-AM 3rd edition code: C22) and stomach (C16) cancer that occurred in New Zealand (2007–2019) were drawn from the New Zealand Cancer Registry (liver cancer: 866 Māori, 2,460 European; stomach cancer: 953 Māori, 3,192 European), and linked to national inpatient hospitalisation records to examine access to surgery. We found that Māori on average travel 120km for liver cancer surgery, compared to around 60km for Europeans, while a substantial minority of both Māori and European liver cancer patients must travel more than 200km for their first primary liver surgery, and this situation appears worse for Māori (36% vs 29%; adj. OR 1.48, 95% CI 1.09–2.01). No such disparities were observed for stomach cancer. This contrast between cancers is likely driven by the centralisation of liver cancer surgery relative to stomach cancer. In order to support Māori to access liver cancer care, we recommend that additional support is provided to Māori patients (including prospective financial support), and that efforts are made to remotely provide those clinical services that can be decentralised. [ABSTRACT FROM AUTHOR]

Background: There is a growing body of evidence that access to best practice perioperative care varies within our population. In this study, we use national‐level data to begin to address gaps in our understanding of regional variation in post‐operative outcomes within New Zealand. Methods: Using National Collections data, we examined all inpatient procedures in New Zealand public hospitals between 2005 and 2017 (859 171 acute, 2 276 986 elective/waiting list), and identified deaths within 30 days. We calculated crude and adjusted rates per 100 procedures for the 20 district health boards (DHBs), both for the total population and stratified by ethnicity (Māori/European). Odds ratios comparing the risk of post‐operative mortality between Māori and European patients were calculated using crude and adjusted Poisson regression models. Results: We observed regional variations in post‐operative mortality outcomes. Māori, compared to European, patients experienced higher post‐operative mortality rates in several DHBs, with a trend to higher mortality in almost all DHBs. Regional variation in patterns of age, procedure, deprivation and comorbidity (in particular) largely drives regional variation in post‐operative mortality, although variation persists in some regions even after adjusting for these factors. Inequitable outcomes for Māori also persist in several regions despite adjustment for multiple factors, particularly in the elective setting. Conclusions: The persistence of variation and ethnic disparities in spite of adjustment for confounding and mediating factors suggests that multiple regions require additional resource and support to improve outcomes. Efforts to reduce variation and improve outcomes for patients will require both central planning and monitoring, as well as region‐specific intervention. [ABSTRACT FROM AUTHOR]

Background: Worldwide, coronavirus disease 2019 (COVID‐19) has significantly challenged the delivery of healthcare. New Zealand (NZ) faced similar potential challenges despite being geographically isolated. Given the rapid change in the COVID‐19 pandemic, hospitals in NZ were tasked with formulating their own COVID‐19 responses based on the Ministry of Health's (MoH) recommendations. Methods: This paper evaluates how six metropolitan general surgical departments in NZ had responded to COVID‐19 in terms of changes made to rosters, theatres, clinics, acute admissions as well as additional measures taken to reduce the risk of staff exposure. It also explores how NZ fared in comparison with international guidelines and recommendations. Data from each centre were provided by an appointed clinician. Results: All centres had adapted new rosters and a restructuring of teams. Handovers, multidisciplinary team meetings and educational sessions were held virtually. Different strategies were implemented to ration hospital resources and reduce the risk of staff exposure. Non‐urgent operations, endoscopies and clinics were deferred with allocation of dedicated COVID‐19 operating theatres. Potential COVID‐19 suspects were screened prior to admission and treated separately. Various admission and imaging pathways were utilised to increase efficiency. Conclusion: General surgical departments in NZ had implemented a comprehensive COVID‐19 response but there is room to work towards a more unified national response. Our analysis shows that these centres across NZ had taken a similar approach which was aligned with international practices. [ABSTRACT FROM AUTHOR]

Background: Surgical treatment of gastric cancer in New Zealand is challenging because of a low annual incidence of 400 patients and population dispersal over a wide area with little data on regional treatment trends and outcomes. This investigation was undertaken to evaluate the surgical outcomes of gastric cancer patients presenting to a single upper gastrointestinal centre (WDHB, Waitemata District Health Board) and to compare these to national and international standards. Methods: Data on 135 patients with histologically proven gastric adenocarcinoma presenting between January 2010 and December 2014 were reviewed and compared with nationally available procedural volume data. Results: Sixty of 135 patients were resected (resection rate 44%) and 75 patients were managed with palliative chemotherapy/symptomatic care alone. Twenty‐six patients (43%) received adjuvant or neoadjuvant chemotherapy and only two patients (3%) underwent laparoscopic resection. In resected patients, 90‐day mortality was 1.6%, and 11 patients (18%) developed complications ≥ Clavien‐Dindo grade 3. Fifty‐two patients (87%) had ≥15 lymph nodes resected and 54 patients (90%) had a histological R0 resection. At median follow‐up of 49 months, 30 patients remain alive and disease‐free with 20 true 5‐year disease‐free survivors. National data between 2010 and 2014 showed WDHB performed 20% (338/1710) of gastric resections for all indications in New Zealand. Conclusion: While WDHB is an internationally low volume centre for gastric cancer, surgical outcomes benchmark satisfactorily to international standards. New Zealand's national treatment standards should set aspirational goals for gastric cancer treatment and have a clear strategy to address issues of surgical volume and national service provision. [ABSTRACT FROM AUTHOR]

PURPOSE: This investigation was undertaken to define the barriers to indigenous peoples participating in biobanking and genomic research. METHODS: A literature review was conducted to identify studies reporting on the experience of indigenous peoples with biobanking, tissue banking, and genomic research. Studies pertaining to organ transplantation or blood donation for transfusion were excluded. The databases searched were MEDLINE, EMBASE, PubMed, Web of Science, and Google Scholar, with all literature available until the search date of June 1, 2018, included. The reference lists of all included papers, as well as related review articles, were manually searched to identify additional relevant studies. An inductive approach was used to identify common themes. RESULTS: Seventeen publications discussed the experiences of New Zealand Māori (n = 2), Aboriginal and Torres Strait Islanders (n = 3), Native Hawaiian (n = 4), Native Alaskan (n = 2), American First Nation (n = 2), or multiple ethnicities (n = 4). Across all indigenous peoples, four themes emerged: land, ancestors, culture, and bodily substances are powerfully interconnected and can act on each other; tissue and blood can provide important information (both Western and traditional) about a person; the ownership of specimens—custodians, trustees, or guardians; and the beneficence of the researchers and research team. CONCLUSION: Indigenous communities, like Western populations, are concerned with issues pertaining to handling, treatment, and ownership of tissue as well as knowledge gained from specimen analysis. Unlike many Western populations, indigenous communities have retained a strong sense of cultural connection to ancestors and traditional lands and view biologic specimens as inseparable from these things. [ABSTRACT FROM AUTHOR]

Worldwide, indigenous communities experience diminished health status and poorer health outcomes in comparison to the dominant non-indigenous population. This novel survey demonstrates that both OHNS supervisors and trainees largely understand and acknowledge the importance of providing culturally appropriate health services for Maori but are less familiar with the importance of appraising personal and institutional attitudes towards culture. In conjunction with the New Zealand based surgical training committees, the Maori Health Advisory Group is developing a formalized cultural safety teaching and assessment programme to meet this need and which will form part of a broader RACS strategy to address Maori health equity. [Extracted from the article]

Background Oesophageal adenocarcinoma (OAC) is a lethal condition. The management is typically multifaceted with oesophagectomy being the cornerstone of treatment. Quality performance indicators (QPIs) are objective measurements of aspects of patient's care that affect clinical outcomes. We look to measure a set of clinically relevant QPIs that can be used to capture key aspects of patient management at our institution. Methods all patients with OAC treated from 2010 to 2015, and 2020 to 2021 at Te Whatu Ora Waitemata were included. Patients with secondary metastases to the oesophagus or gastric cancer with extension to the oesophagus were excluded. Electronic data in the form of clinic letters, operation notes, histology and radiology reports were reviewed. QPI adherence was collected in binary form. Results QPIs with consistently high compliance rates include radiological staging and histological diagnosis, perioperative dietitian involvement, explanations of disease and treatment intent, and pathology report documentation. QPIs demonstrating significant change and improvement across the two groups include endoscopic resection (60.0% of patients with T1 disease in 2010 to 88.9% in 2020 group), multimodality treatment (majority ECF and ECX perioperative chemotherapy in 2010 to majority FLOT chemotherapy in 2020 group) and minimally invasive approach (30.4% hybrid in 2010 compared to 72.4% hybrid in 2020). Conclusions QPIs from the systematic review were readily measurable and were variably implemented in clinical practice. Areas requiring improvement were identified however relevance to real-world clinical outcomes require further focus of investigation. [ABSTRACT FROM AUTHOR]

New Zealand Maori make up nearly 15% of the population of New Zealand, and their population has increased significantly in the last 20 years. Because of this, the average age of Maori is only 22.7 years with 35% of Maori aged 15 years or less. In spite of this youthful profile, the Maori population has high health needs with trauma, ear disease, respiratory disease and infectious diseases as significant causes of hospitalisation and death. The role of surgery in the management of three potentially preventable but significant health issues affecting Maori children - trauma, cutaneous sepsis (cellulitis and superficial abscess) and obesity - is reviewed. [ABSTRACT FROM AUTHOR]

Hepatocellular carcinoma (HCC) is the most common primary malignancy of the liver. Treatment options include liver resection, tumor ablation, and liver transplantation. We report the results of all patients undergoing partial hepatectomy for HCC with curative intent from a center where all major treatment modalities were available. A series of 53 patients were identified, of whom 72% had underlying liver disease, mostly chronic hepatitis B infection. Altogether, 57% of patients underwent major resections, of whom 43% had histologically proven cirrhosis. Postoperative morbidity and mortality occurred in 41.5% and 7.5%, respectively. After a median follow-up of 34 months, the survival probabilities at 1, 3, and 5 years were 74.1%, 54.1%, and 42.6%, respectively. A total of 47% developed recurrent disease over the study period with a median disease-free survival of 13.8 months. The probabilities of recurrence at 1, 3, and 5 years were 35.2%, 49.4%, and 55.9%, respectively. Among those who developed recurrence, 76% died, with a median time to death from the time the recurrence was diagnosed of 7.8 months. There was a good association between the CLIP score and survival following liver resection. Multivariate analysis showed that only tumor recurrence and the presence of cirrhosis was a significant determinant of the risk of tumor-related death. These findings confirm that with careful patient selection liver resection for HCC can achieve good long-term patient survival and acceptable risks. [ABSTRACT FROM AUTHOR]

The author discusses the case of a 40-year-old female who undergone the elective liver resection in April 1975. According to the author, it was the first elective liver resection for cancer in New Zealand wherein there was no available cross-sectional radiological imaging in the country. He emphasizes that despite the lack of available preoperative imaging, surgical precedent, and staging information, the surgery became successful due to the faith and cooperation between patient and surgeon.

Introduction: The aim of present paper was to document the incidence of gall bladder cancer, cancer of the extrahepatic bile ducts and ampullary carcinoma in New Zealand. Methods: Data were collected from the New Zealand Cancer Registry from 1980 to 1997 and combined with national census statistics to give crude and age standardized incidence rates. Results: Over the 18-year study period, 226 carcinomas of the ampulla of Vater, 608 gall bladder cancers, and 486 extrahepatic cholangiocarcinomas were registered. The age standardized incidence rates for gall bladder carcinoma in all New Zealanders were 0.41/100 000 in men and 0.74/100 000 in women. The age standardized incidence rates for gall bladder cancer in Maori were 1.49/100 000 in Maori men and 1.59/100 000 in Maori women. The corresponding age standardized incidence rates for extrahepatic bile duct cancers were 0.67/100 000 in men and 0.45/100 000 in women. There were insufficient cases to calculate an age standardized incidence in Maori or Pacific Islanders. For carcinoma of the ampulla, the age standardized rates were 0.34/100 000 in men and 0.25/100 000 in women. There were insufficient cases to calculate an age standardized incidence rate for Maori or Pacific Islanders. When histology was defined adenocarcinoma was the most common form of cancer occurring in 66% of gall bladder cancers, 91% of extrahepatic bile duct cancers and 70% of ampullary cancers. Most tumours were advanced at presentation with regional or distant metastases present in 72% of gall bladder cancers, 63% of extrahepatic bile duct cancers and 69% of ampullary tumours at diagnosis. Survival was poor with median survivals of 86 days, 151 days and 440 days recorded for gall bladder cancer, extrahepatic bile duct cancer and ampullary cancer, respectively. Conclusions: The demographic profile, pathology and survival of patients with gall bladder cancer, extrahepatic bile duct cancer and ampullary carcinoma are similar in New Zealand to... [ABSTRACT FROM AUTHOR]

• Half of all lung cancers in NZ are preceded by an emergency hospitalisation. • This rate is highest for Pacific (62%) and Indigenous Māori (54%) with lung cancer. • Pacific have 50% and Māori 21% higher adjusted odds of emergency hospitalisation. • Survival is substantially worse when diagnosed following emergency hospitalisation. A recent multinational investigation of emergency presentation within 30 days of cancer diagnosis, conducted within the International Cancer Benchmarking Programme (ICBP), observed that New Zealand had the highest rate of emergency presentation prior to lung cancer diagnosis compared to other similar countries. Here we use national-level health data to further investigate these trends, focussing on ethnic disparities in emergency presentation prior to lung cancer diagnosis. We have also compared survival outcomes between those who had an emergency presentation in the preceding 30 days to those who did not. Our study included all lung cancer registrations between 2007 and 2019 on the New Zealand Cancer Registry (N = 27,869), linked to national hospitalisation and primary healthcare data. We used descriptive (crude and age-standardised proportions) and logistic regression (crude and adjusted odds ratios) analyses to examine primary care access prior to cancer diagnosis, emergency hospitalisation up to and including 30 days prior to diagnosis, and one-year mortality post-diagnosis, both for the total population and between ethnicities. Regression models adjusted for age, sex, deprivation, rurality, comorbidity, tumour type and stage. We found stark disparities by ethnic group, with 62% of Pacific peoples and 54% of Māori having an emergency presentation within 30 days prior to diagnosis, compared to 47% of Europeans. These disparities remained after adjusting for multiple covariates including comorbidity and deprivation (adj. OR: Māori 1.21, 95% CI 1.13–1.30; Pacific 1.50, 95% CI 1.31–1.71). Emergency presentation was associated with substantially poorer survival outcomes across ethnic groups (e.g. 1-year mortality for Māori: no emergency presentation 50%, emergency presentation 79%; adj. OR 2.40, 95% CI 2.10–2.74). These observations reinforce the need for improvements in the early detection of lung cancer, particularly for Māori and Pacific populations, with a view to preventing diagnosis of these cancers in an emergency setting. [ABSTRACT FROM AUTHOR]

Purpose: Information on cancer stage at diagnosis is critical for population studies investigating cancer care and outcomes. Few studies have examined the factors which impact (1) staging or (2) outcomes for patients who are registered as having unknown stage. This study investigated (1) the prevalence of unknown stage at diagnosis on the New Zealand Cancer Registry (NZCR); (2) explored factors which predict unknown stage; (3) described receipt of surgery and (4) survival outcomes for patients with unknown stage. Methods: Patients diagnosed with the most prevalent 18 cancers between 2006 and 2008 (N = 41,489) were identified from the NZCR, with additional data obtained from mortality and hospitalisation databases. Logistic and Cox regression were used to investigate predictors of unknown stage and patient outcomes. Results: (1) Three distinct groups of cancers were found based on proportion of patients with unknown stage (low = up to 33% unknown stage; moderate = 33-64%; high = 65%+). (2) Increasing age was a significant predictor of unknown stage (adjusted odds ratios [ORs]: 1.18-1.24 per 5- year increase across groups). Patients with substantive comorbidity were more likely to have unknown stage but only for those cancers with a low (OR = 2.65 [2.28-3.09]) or moderate (OR = 1.17 [1.03-1.33]) proportion of patients with unknown stage. (3) Patients with unknown stage were significantly less likely to have received definitive surgery than those with local or regional disease across investigated cancers. (4) Patients with unknown stage had 28-day and 1-year survival which was intermediate between regional and distant disease. Discussion: We found that stage completeness differs widely by cancer site. In many cases, the proportion of unknown stage on a population-based register can be explained by patient, service and/or cancer related factors. [ABSTRACT FROM AUTHOR]

Background: Haematological ('blood') cancers are a diverse group of non-solid cancers with varying incidence, mortality and survival. While there is some evidence that Māori experience disparities in blood cancer outcomes relative to New Zealand's majority European population, there is a need for a comprehensive overview of the current state of evidence in this context., Methods: Blood cancer registrations were derived from the NZ Cancer Registry for the 2007-2019 period (combined blood cancers: 2653 Māori, 20,458 Europeans), and linked to Mortality records. We calculated age-sex-standardised incidence and mortality rates, and conducted cancer-specific survival analysis, for four main categories of blood cancers (leukaemia, Hodgkin lymphoma, non-Hodgkin lymphoma and myeloma) as well as for sub-types of leukaemia non-Hodgkin lymphoma., Results: We found that Māori are more likely to be diagnosed with (incidence) and to die from (mortality) both leukaemia and myeloma, and similarly likely to be diagnosed or die from Hodgkin and non-Hodgkin lymphoma, compared to Europeans. Māori had demonstrably poorer cancer-specific survival outcomes across most blood cancer types (age-sex-adjusted hazard ratios [HRs], Māori vs European: leukaemia 1.77, 95 % CI 1.57-2.00; Hodgkin lymphoma 1.18, 95 % CI 0.65-2.16; non-Hodgkin lymphoma 1.71, 95 % CI 1.50-1.95; myeloma 1.40, 95 % CI 1.19-1.64)., Conclusion: Blood cancers are a common cancer type for Māori, and we found evidence of disparities in incidence, mortality and survival compared to Europeans. Further research is required to further pinpoint exactly where interventions should be aimed to reduce blood cancer incidence and address survival disparities for Māori., Competing Interests: Declaration of Competing Interest None., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Background: Māori are less likely to survive their lung cancer once diagnosed, but it remains unclear whether this is partially driven by poorer access to best-practice diagnostic services., Methods: We examined all lung cancer registrations in Aotearoa New Zealand between 2007-2019 (n=27,869) linked to national administrative health datasets and further stratified by ethnicity, tumour type and stage of disease. Using descriptive and regression analyses, we compared ethnic groups in terms of the basis of diagnosis (e.g., histology, cytology), receipt of bronchoscopy and travel distance and time to access bronchoscopy., Results: We found no differences in access to a pathological diagnosis between ethnic groups regardless of cancer type or stage. We found that Māori within the cohort were marginally more likely to access bronchoscopy than the majority European group; however, we also found that Māori had lower odds of living close to the location of their bronchoscopy, and correspondingly higher odds of living 100-200km (adjusted odds ratio [adj. OR] 1.46, 95% confidence interval [CI] 1.26-1.69) or more than 200km away (1.36, 95% CI 1.15-1.61) than Europeans., Conclusion: Interventions that aim to further support Māori to overcome the systematic and cumulative disadvantages in access to cancer care should be broadly supported and resourced., Competing Interests: The authors have no relevant financial or non-financial interests to disclose., (© PMA.)

Introduction: Emergency laparotomy (EL) is a high-risk operation which is increasingly performed on an aging patient population. Objective frailty assessment using a validated index has the potential to improve preoperative risk stratification. This study aimed to assess the correlation between frailty and long-term mortality and morbidity outcomes for older EL patients. Secondary aims were to compare the 11-item and shortened five-item modified frailty indices (mFIs) in terms of value and predictive validity., Methods: A prospective multicenter observational study of patients aged ≥55 y undergoing EL was conducted across five hospitals in New Zealand between 2017 and 2022. Frailty was measured using the 11-item and abbreviated five-item mFIs. Multivariable logistic regression was used to determine whether frailty was independently associated with one-year postoperative mortality and other morbidity outcomes. Correlation between the two frailty indices were assessed with the Spearman's correlation coefficient (P)., Results: Frailty assessments were performed in 861 participants, with the prevalence being 18.7% and 29.8% using the 11-item and five-item mFIs, respectively. Both frailty indices demonstrated similar associations with one-year mortality (two-fold increased risk), major complications, admission to intensive care unit, rehabilitation, and 30-d readmission. The 11-item mFI demonstrated a greater association with early mortality (four-fold increased risk), reoperations, and increased length of stay compared with the five-item frailty index. Spearman P was 0.6 (P < 0.001)., Conclusions: Frailty, as identified by the 11-item and five-item mFIs, was associated with one-year mortality and other important morbidity outcomes for older EL patients. These forms of frailty assessment provide important information that may aid in risk assessment and patient-centered decision-making., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Quality performance indicators for the management of oesophagogastric cancer can be used to objectively measure and compare the performance of individual units and capture key elements of patient care to improve patient outcomes., Methods: Two systematic reviews were completed to identify evidence-based quality performance indicators for the surgical management of oesophagogastric cancer. Based on the indicators identified, a two-round modified Delphi process with invitations was sent to all members of the Australia and Aotearoa New Zealand Gastric and Oesophageal Surgery Association. The expert working group discussed each suggested indicator and either removed, added, or adjusted the list of indicators of oesophagogastric cancer., Results: The final list of both OG cancer indicators included Specialized Multi-disciplinary team discussion, Endoscopy documentation, Staging Contrast CT Chest/Abdomen and Pelvis, Neoadjuvant or Adjuvant chemo/radiotherapy administered in accordance with the Local multi-disciplinary team, Pathological margin clearance (R0 Resection), Lymphadenectomy retrieving 15 or more nodes, Formal review of pathological findings and documentation, Postoperative complications, 30-day and 90-day postoperative mortality, clinical surveillance and Specialized Dietetic guidance. Indicators specific to gastric cancer included Preoperative biopsy for pathological diagnosis and Staging Laparoscopy. Indicators specific to oesophageal cancer include positron emission tomography scan if CT negative for metastasis, Perioperative Oesophagectomy Care Pathway, length of stay of 21 days or more, and Unplanned readmission within 30 days., Conclusions: The results of this study present a core set of indicators for the surgical management of oesophagogastric cancer that can be used to measure quality and compare performance between different units., (© 2024 Royal Australasian College of Surgeons.)

Aim: The primary aim of the study is to define the post-colonoscopy colorectal cancer (PCCRC) three-year rate and the post-endoscopy upper gastrointestinal cancer (PEUGIC) three-year rate across public hospitals in Aotearoa New Zealand., Method: This retrospective cohort study will be conducted via the trainee-led STRATA Collaborative network. All public hospitals in Aotearoa New Zealand will be eligible to participate. Data will be collected on all adult patients who are diagnosed with colorectal adenocarcinoma within 6 to 48 months of a colonoscopy and all adult patients diagnosed with gastroesophageal cancer within 6 to 48 months of an upper gastrointestinal endoscopy. The study period will be from 2010 to 2022. The primary outcome is the PCCRC 3-year rate and the PEUGIC 3-year rate. Secondary aims are to define and characterize survival after PCCRC or PEUGIC, the cause of PCCRC as based on the World Endoscopy Organization System of Analysis definitions, trends over time, and centre level variation., Conclusion: This protocol describes the methodology for a nationwide retrospective cohort study on PCCRC and PEUGIC in Aotearoa New Zealand. These data will lay the foundation for future studies and quality improvement initiatives., (© 2024 The Author(s). Colorectal Disease published by John Wiley & Sons Ltd on behalf of Association of Coloproctology of Great Britain and Ireland.)

Aim: This feasibility study was undertaken to implement and assess a Rongoā Māori (traditional Māori healing)/Western medicine collaboration model in a general surgical outpatient setting., Methods: Six patients were recruited and consulted with both a Rongoā Māori practitioner and a Western trained surgeon three times in 6 months. Appointments were an average of 45 minutes duration, patient whānau (family) were welcome and kai (food) was provided as a culturally appropriate custom. Qualitative interviews were conducted with patients, whānau and practitioners after the final appointment with practitioners. The data were thematically analysed and reviewed by the team researchers., Results: Seven themes were identified from the successful collaboration: benefits of Rongoā/medical collaboration to participants; the high value of healer/doctor relationships with participants; participants' experiences of healer/doctor collaboration; healer/doctor perceptions of the Rongoā/medical collaboration process; paying attention to the ecosystem of each participant; unanimous support for Rongoā/medical collaboration to be implemented in the health system; suggestions for Rongoā/medical collaboration improvement., Conclusions: Many challenges remain, but collaboration between Rongoā Māori healing and Western health professionals in public hospitals is not only possible, but also meets the need for patient-centred care., Competing Interests: This investigation has not previously been presented or accepted for presentation or publication and was funded by a New Zealand Health Delivery Grant from the Health Research Council of New Zealand (21/1079)., (© PMA.)

Background: Cancer is a major cause of premature death and inequity, and global case numbers are rapidly expanding. This study projects future cancer numbers and incidence rates in Aotearoa New Zealand., Methods: Age-period-cohort modelling was applied to 25-years of national data to project cancer cases and incidence trends from 2020 to 2044. Nationally mandated cancer registry data and official historical and projected population estimates were used, with sub-groups by age, sex, and ethnicity., Results: Cancer diagnoses were projected to increase from 25,700 per year in 2015-2019 to 45,100 a year by 2040-44, a 76% increase (2.3% per annum). Across the same period, age-standardised cancer incidence increased by 9% (0.3% per annum) from 348 to 378 cancers per 100,000 person years, with greater increases for males (11%) than females (6%). Projected incidence trends varied substantially by cancer type, with several projected to change faster or in the opposite direction compared to projections from other countries., Conclusions: Increasing cancer numbers reinforces the critical need for both cancer prevention and treatment service planning activities. Investment in developing new ways of working and increasing the workforce are required for the health system to be able to afford and manage the future burden of cancer., Competing Interests: Declaration of Competing Interest The authors declare the following financial interests/personal relationships which may be considered as potential competing interests: Andrea Teng, James Stanley, Chunhuan Lao, Ross Lawrenson and Jason Gurney report financial support was provided by Health Research Council of New Zealand., (Copyright © 2024 The Authors. Published by Elsevier Ltd.. All rights reserved.)

Objectives: The objective of this study is to investigate the influence of diabetes on breast cancer-specific survival among women with breast cancer in Aotearoa/New Zealand., Methods: This study included women diagnosed with invasive breast cancer between 2005 and 2020, with their information documented in the Te Rēhita Mate Ūtaetae-Breast Cancer Foundation National Register. Breast cancer survival curves for women with diabetes and those without diabetes were generated using the Kaplan-Meier method. The hazard ratio (HR) of breast cancer-specific mortality for women with diabetes compared to women without diabetes was estimated using the Cox proportional hazards model., Results: For women with diabetes, the 5-year and 10-year of cancer-specific survival were 87% (95% CI: 85%-88%) and 79% (95% CI: 76%-81%) compared to 89% (95% CI: 89%-90%) and 84% (95% CI: 83%-85%) for women without diabetes. The HR of cancer-specific mortality for patients with diabetes compared to those without diabetes was 0.99 (95% CI: 0.89-1.11) after adjustment for patient demographics, tumor characteristics, and treatments. Age at cancer diagnosis and cancer stage had the biggest impact on the survival difference between the two groups. When stratified by cancer stage, the cancer-specific mortality between the two groups was similar., Conclusions: While differences in survival have been identified for women with diabetes when compared to women without diabetes, these are attributable to age and the finding that women with diabetes tend to present with more advanced disease at diagnosis. We did not find any difference in survival between the two groups due to differences in treatment., (© 2024 The Authors. Cancer Reports published by Wiley Periodicals LLC.)

Purpose: Centralisation of lung cancer treatment can improve outcomes, but may result in differential access to care for those who do not reside within treatment centres., Methods: We used national-level cancer registration and health care access data and used Geographic Information Systems (GIS) methods to determine the distance and time to access first relevant surgery and first radiation therapy among all New Zealanders diagnosed with lung cancer (2007-2019; N = 27,869), and compared these outcomes between ethnic groups. We also explored the likelihood of being treated at a high-, medium-, or low-volume hospital. Analysis involved both descriptive and adjusted logistic regression modelling., Results: We found that Māori tend to need to travel further (with longer travel times) to access both surgery (median travel distance: Māori 57 km, European 34 km) and radiation therapy (Māori 75 km, European 35 km) than Europeans. Māori have greater odds of living more than 200 km away from both surgery (adjusted odds ratio [aOR] 1.83, 95% CI 1.49-2.25) and radiation therapy (aOR 1.41, 95% CI 1.25-1.60)., Conclusions: Centralisation of care may often improve treatment outcomes, but it also makes accessing treatment even more difficult for populations who are more likely to live rurally and in deprivation, such as Māori., (© 2024. The Author(s).)

Purpose: Lung cancer is the biggest cancer killer of indigenous peoples worldwide, including Māori people in New Zealand. There is some evidence of disparities in access to lung cancer treatment between Māori and non-Māori patients, but an examination of the depth and breadth of these disparities is needed. Here, we use national-level data to examine disparities in access to surgery, radiation therapy and systemic therapy between Māori and European patients, as well as timing of treatment relative to diagnosis., Methods: We included all lung cancer registrations across New Zealand from 2007 to 2019 (N = 27,869) and compared access with treatment and the timing of treatment using national-level inpatient, outpatient, and pharmaceutical records., Results: Māori patients with lung cancer appeared less likely to access surgery than European patients (Māori, 14%; European, 20%; adjusted odds ratio [adj OR], 0.82 [95% CI, 0.73 to 0.92]), including curative surgery (Māori, 10%; European, 16%; adj OR, 0.72 [95% CI, 0.62 to 0.84]). These differences were only partially explained by stage and comorbidity. There were no differences in access to radiation therapy or systemic therapy once adjusted for confounding by age. Although it appeared that there was a longer time from diagnosis to radiation therapy for Māori patients compared with European patients, this difference was small and requires further investigation., Conclusion: Our observation of differences in surgery rates between Māori and European patients with lung cancer who were not explained by stage of disease, tumor type, or comorbidity suggests that Māori patients who may be good candidates for surgery are missing out on this treatment to a greater extent than their European counterparts.

Robot-assisted surgery refers to a surgeon controlling a robotic device that performs an operation. This viewpoint explores the current state of robot-assisted surgery in Aotearoa New Zealand using the da Vinci Surgical System (Intuitive Surgical, Sunnyvale, California, United States), the only currently available robotic surgical system for general surgery in the country. We describe the contemporary progress in Aotearoa New Zealand compared to Australia and globally, and present emerging high-level evidence from randomised controlled trials regarding the utility of the robot-assisted approach for general surgery procedures. From the available evidence, we suggest that the value of robot-assisted general surgery in the public healthcare system arises from its emerging clinical benefits for complex procedures and its potential to engender equitable access and outcomes, particularly for Māori and Pacific peoples, improve education and training and contribute towards quality assurance and workforce development. Therefore, its implementation aligns with the New Zealand Health Strategy's long-term goals and priority areas to achieve pae ora, healthy futures for all., Competing Interests: The authors declare no conflicts of interest. None of the authors have received any payment from Intuitive Surgical, Device Technologies or any of their subsidiaries., (© PMA.)

Purpose: The co-occurrence of diabetes and cancer is becoming increasingly common, and this is likely to compound existing inequities in outcomes from both conditions within populations., Methods: In this study, we investigate the co-occurrence of cancer and diabetes by ethnic groups in New Zealand. National-level diabetes and cancer data on nearly five million individuals over 44 million person-years were used to describe the rate of cancer in a national prevalent cohort of peoples with diabetes versus those without diabetes, by ethnic group (Māori, Pacific, South Asian, Other Asian, and European peoples)., Results: The rate of cancer was greater for those with diabetes regardless of ethnic group (age-adjusted rate ratios, Māori, 1.37; 95% CI, 1.33 to 1.42; Pacific, 1.35; 95% CI, 1.28 to 1.43; South Asian, 1.23; 95% CI, 1.12 to 1.36; Other Asian, 1.31; 95% CI, 1.21 to 1.43; European, 1.29; 95% CI, 1.27 to 1.31). Māori had the highest rate of diabetes and cancer co-occurrence. Rates of GI, endocrine, and obesity-related cancers comprised a bulk of the excess cancers occurring among Māori and Pacific peoples with diabetes., Conclusion: Our observations reinforce the need for the primordial prevention of risk factors that are shared between diabetes and cancer. Also, the commonality of diabetes and cancer co-occurrence, particularly for Māori, reinforces the need for a multidisciplinary, joined-up approach to the detection and care of both conditions. Given the disproportionate burden of diabetes and those cancers that share risk factors with diabetes, action in these areas is likely to reduce ethnic inequities in outcomes from both conditions.

Purpose: This study aims to examine the association of diabetes and breast cancer characteristics at diagnosis in Aotearoa/New Zealand., Methods: Patients diagnosed with invasive breast cancer between 2005 and 2020 were identified from the National Breast Cancer Register. Logistic regression modeling was used to estimate the adjusted odds ratio (OR) of having stage III-IV cancer and the OR of having stage IV cancer for women with diabetes compared to those without diabetes. The adjusted OR of having screen-detected breast cancers for patients aged 45-69 years with diabetes compared to patients without diabetes was estimated., Results: 26,968 women were diagnosed with breast cancer, with 3,137 (11.6%) patients having diabetes at the time of cancer diagnosis. The probability of co-occurrence of diabetes and breast cancer increased with time. Māori, Pacific and Asian women were more likely to have diabetes than European/Others. The probability of having diabetes also increased with age. For patients with diabetes, the probability of being diagnosed with stage III-IV cancer and stage IV cancer was higher than for patients without diabetes (OR 1.14, 95% CI 1.03-1.27; and 1.17, 95% CI 1.00-1.38). Women aged 45-69 years with diabetes were more likely to have screen-detected cancer than those without diabetes (OR 1.13, 95% CI 1.02-1.26)., Conclusions: The co-occurrence of diabetes and breast cancer is becoming more common. Overall there is a small but significant adverse impact of having advanced disease for women with diabetes that is found at the time of breast cancer diagnosis, and this may contribute to other inequities that occur in the treatment pathway that may impact on patient outcomes., (© 2022. The Author(s), under exclusive licence to Springer Nature Switzerland AG.)

Liver cancer is among the most commonly diagnosed and least-survivable cancers in New Zealand. There are stark disparities between the Indigenous Māori population in incidence of and mortality from liver cancer relative to non-Māori. In this review, we have summarised the key risk factors for liver cancer, and the key activities undertaken in New Zealand, over time, to control this disease, with a focus on how risk factors and interventions aimed at reducing them differentially impact Māori. We have conducted a narrative literature review. The disproportionate burden of liver cancer experienced by Māori is primarily driven by disparities in viral exposure to hepatitis B and C between ethnic groups. Efforts to control hepatitis-associated liver cancer in New Zealand have lacked national coordination, further driving disparities in liver cancer survival between Māori and NZ Europeans. A national primary care-based programme to detect and treat hepatitis B and C and to screen for liver cancer among high-risk patients, along with renewed effort to maximise hepatitis B vaccination rates, has the potential to substantially reduce the burden of hepatitis-associated liver cancer and address a significant health disparity between Māori and non-Māori., Competing Interests: Nil., (© PMA.)

There is an urgent need for high-quality evidence regarding post-operative mortality among Indigenous peoples. Our group recently published a national audit of 4,000,000 procedures conducted between 2005-2017, which identified considerable disparities in post-operative mortality between Indigenous Māori and non-Indigenous New Zealanders. Understanding the primary drivers of these disparities-for Māori, but likely also other Indigenous populations worldwide-requires us to consider the multiple levels at which these drivers might arise. To that end, in this paper we breakdown these drivers in detail, conceptualising these drivers as operating in layers with each factor leading to the next. These layers include structural factors, care system factors, care process factors, care team factors and patient factors. Each of these factors are presented within a framework that can be used to begin to understand them - with a view to rousing action and inspiring intervention to address inequities in post-operative outcomes experienced by Indigenous peoples., Competing Interests: Nil., (© PMA.)

Aim: An online survey was undertaken to analyse the perception of medical school graduates, in postgraduate years 1 and 2, of being ready to work (preparedness) and of managing the demands of practice as a junior doctor on a general surgical attachment., Methods: An email-based survey was designed to assess medical school graduates' sense of preparedness, and was sent electronically to all house officers at the beginning of their 3-month attachment in general surgery between December 2020 and December 2021. One email reminder was sent 2 weeks after the initial email with the embedded survey hyperlink., Results: The overall response rate was 50%. Of those, over 90% had accompanied surgical teams on acute calls and over extended hours as a medical student. However, only 50% had ever attended a trauma call or a resuscitation call with clinical teams. Half of the respondents indicated that they would have liked specific teaching on mental and physical self-care, preparation for night shifts and extended periods of duty as well as in prioritisation, delegation and management of workloads., Conclusion: This survey showed that new doctors lacked dedicated teaching in professional behaviours and felt it to be an important part of medical training and preparation for medical practice., Competing Interests: Nil., (© PMA.)

Purpose: Around a third of people with cancer will die outside of their preferred place of death, with substantial variation occurring between and within countries in terms of place of death. Here, we examine place of death within the New Zealand cancer context, with specific focus on differences between Indigenous Māori and other ethnic groups., Methods: Using national-level data, we identified all those who died in New Zealand between 2007 and 2018 of cancer (N = 107,373), stratified by ethnicity and cancer type, and linked these patients to national health and mortality records. We then described the crude and age-standardized proportions of cancer deaths by location separately by ethnic group, and conducted logistic regression to compare odds of death within a given location between ethnic groups., Results: After adjusting for age, sex, and deprivation, we found that Māori people with cancer are more likely to die in a private residence than Europeans (46% v 26%; odds ratio [OR] 2.45; 95% CI, 2.36 to 2.55), and also somewhat more likely to die in hospital (27% v 23%; OR 1.26; 95% CI, 1.21 to 1.32). Commensurately, Māori are less likely to die in either hospice inpatient unit (14% v 27%; OR 0.48; 95% CI, 0.45 to 0.51) or residential care (12% v 30%; OR 0.56; 95% CI, 0.52 to 0.59). Pacific patients generally follow the same pattern as Māori patients. These findings were largely repeated across cancer types, with some variation in the magnitude not overall pattern., Conclusion: It remains unclear whether these differences reflect differences in preferences for place of death between ethnic groups, or whether they reflect differences in access to appropriate supportive care. Further research is required to examine these differences in greater detail., Competing Interests: James StanleyStock and Other Ownership Interests: Gains Psychology Lower Hutt, New Zealand (I) Jonathan KoeaResearch Funding: Ethicon (Inst)No other potential conflicts of interest were reported.

Objectives: When combined, liver and stomach cancers are second only to lung cancer as the most common causes of cancer death for the indigenous Māori population of New Zealand-with Māori also experiencing substantial disparities in the likelihood of survival once diagnosed with these cancers. Since a key driver of this disparity in survival could be access to surgical treatment, we have used national-level data to examine surgical procedures performed on Māori patients with liver and stomach cancers and compared the likelihood and timing of access with the majority European population., Design, Participants and Setting: We examined all cases of liver and stomach cancers diagnosed during 2007-2019 on the New Zealand Cancer Registry (liver cancer: 866 Māori, 2460 European; stomach cancer: 953 Māori, 3192 European) and linked these cases to all inpatient hospitalisations that occurred over this time to identify curative and palliative surgical procedures. As well as descriptive analysis, we compared the likelihood of access to a given procedure between Māori and Europeans, stratified by cancer and adjusted for confounding and mediating factors. Finally, we compared the timing of access to a given procedure between ethnic groups., Results and Conclusions: We found that (a) access to liver transplant for Māori is lower than for Europeans; (b) Māori with stomach cancer appear more likely to require the type of palliation consistent with gastric outlet obstruction; and (c) differential timing of first stomach cancer surgery between Māori and European patients. However, we may also be cautiously encouraged by the fact that differences in overall access to curative surgical treatment were either marginal (liver) or absent (stomach)., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Aim: To describe disparities in post-operative mortality experienced by Indigenous Māori compared to non-Indigenous New Zealanders., Methods: We completed a national study of all those undergoing a surgical procedure between 2005 and 2017 in New Zealand. We examined 30-day and 90-day post-operative mortality for all surgical specialties and by common procedures. We compared age-standardised rates between ethnic groups (Māori, Pacific, Asian, European, MELAA/Other) and calculated hazard ratios (HRs) using Cox proportional hazards regression modelling adjusted for age, sex, deprivation, rurality, comorbidity, ASA score, anaesthetic type, procedure risk and procedure specialty., Results: From nearly 3.9 million surgical procedures (876,976 acute, 2,990,726 elective/waiting list), we observed ethnic disparities in post-operative mortality across procedures, with the largest disparities occurring between Māori and Europeans. Māori had higher rates of 30- and 90-day post-operative mortality across most broad procedure categories, with the disparity between Māori and Europeans strongest for elective/waiting list procedures (eg, elective/waiting list musculoskeletal procedures, 30-day mortality: adj. HR 1.93, 95% CI 1.56-2.39)., Conclusions: The disparities we observed are likely driven by a combination of healthcare system, process and clinical team factors, and we have presented the key mechanisms within these factors., Competing Interests: Dr Ongley is Chair of the Perioperative Mortality Review Committee for HQSC. Dr McLeod reports grants from HRC during the conduct of this study.

Objectives: In this manuscript, we describe broad trends in postoperative mortality in New Zealand (a country with universal healthcare) for acute and elective/waiting list procedures conducted between 2005 and 2017., Design, Participants and Setting: We use high-quality national-level hospitalisation data to compare the risk of postoperative mortality between demographic subgroups after adjusting for key patient-level confounders and mediators. We also present temporal trends and consider how rates in postoperative death following acute and elective/waiting list procedures have changed over this time period., Results and Conclusion: A total of 1 836 683 unique patients accounted for 3 117 374 admissions in which a procedure was performed under general anaesthetic over the study period. We observed an overall 30-day mortality rate of 0.5 per 100 procedures and a 90-day mortality rate of 0.9 per 100. For acute procedures, we observed a 30-day mortality rate of 1.6 per 100, compared with 0.2 per 100 for elective/waiting list procedures. In terms of procedure specialty, respiratory and cardiovascular procedures had the highest rate of 30-day mortality (age-standardised rate, acute procedures: 3-6 per 100; elective/waiting list: 0.7-1 per 100). As in other contexts, we observed that the likelihood of postoperative death was not proportionally distributed within our population: older patients, Māori patients, those living in areas with higher deprivation and those with comorbidity were at increased risk of postoperative death, even after adjusting for all available factors that might explain differences between these groups. Increasing procedure risk (measured using the Johns Hopkins Surgical Risk Classification System) was also associated with an increased risk of postoperative death. Encouragingly, it appears that risk of postoperative mortality has declined over the past decade, possibly reflecting improvements in perioperative quality of care; however, this decline did not occur equally across procedure specialties., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Cancer is an important cause of morbidity and avoidable mortality for Māori-and substantial disparities exist in cancer incidence, mortality and survival for Māori compared to non-Māori New Zealanders. In this viewpoint, we draw together cancer incidence, mortality and survival data from the previous decade, in order to provide clarity regarding the most important causes of cancer burden for Māori. Covering the decade 2007-2016, our manuscript directly leads on from the landmark Unequal Impact II report (which covered 1996-2006), and provides the most up-to-date record of this burden as is currently possible. While focusing on the absolute burden of cancer for Māori, we also compare this burden to that experienced by non-Māori, and consider how this relative disparity may (or may not) have changed over time. Finally, we discuss how to reduce the occurrence and the overall cancer mortality burden for Māori, with a focus on those cancers that confer the greatest burden., Competing Interests: All authors report grants from Health Research Council during the conduct of the study.

Purpose: While cancer survival is improving across most developed nations, those improvements are not shared equally within their population. Using high-quality national data, we have reviewed the extent to which cancer survival inequities are persisting for indigenous Māori compared with non-Māori New Zealanders and the extent to which these disparities are driven by deprivation, comorbidity, and stage of disease., Methods: Incident cases of cancer (2007-2016) were extracted from the New Zealand Cancer Registry and linked to mortality and hospitalization data. Descriptive, Kaplan-Meier, and Cox regression methods were used to compare survival outcomes between Māori and non-Māori., Results: Māori continue to have poorer survival than non-Māori for 23 of the 24 most common causes of Māori cancer death, with the extent of this disparity ranging from 12% to 156%. The magnitude of these disparities varies according to deprivation, comorbidity, and stage. Of note, there was a tendency for survival disparities to be largest among those with no comorbidity., Conclusion: Māori continue to experience substantial cancer survival inequities. These observations are in keeping with reports from previous decades, which suggest that these disparities persist despite heightened attention. Reduction of the cancer burden on Māori and achievement of equitable survival outcomes require us to prevent cancer for Māori where we can, diagnose Māori patients early when we cannot, and once diagnosed, deliver equitable care to Māori patients at each step along the treatment path.

Background: This investigation was undertaken to define the factors determining the optimal and most productive relationship among indigenous communities, surgeons, and providers of surgical services., Methods: A systematic literature review was conducted to identify studies reporting on the experience of indigenous communities with surgeons, medical practitioners, and the providers of surgical and other health services. The databases searched were MEDLINE, EMBASE, PubMed, Web of Science, and Google Scholar, including all literature available until the search date of April 3, 2019. The reference lists of all included articles and related review articles were searched manually to identify further relevant studies. An inductive approach was used to identify common themes., Results: Thirty-three publications discussed the experiences of New Zealand Māori (n = 2), Aboriginal and Torres Strait Islanders (n = 20), North American First Nation (n = 10), and Indigenous Latin Americans (n = 1). Across all indigenous peoples, 6 themes emerged: accessible health services, community participation and community governance, continuous quality improvement, a culturally appropriate and clinically skilled workforce, a flexible approach to care, and holistic healthcare., Conclusion: To provide medical and surgical services in indigenous communities successfully requires a diverse range of skills and core technical and academic competencies. Many skills lie within the definition of professionalism and advocacy as well as the ability to undertake and operationalize community consultation and empowerment. If surgical services serving Indigenous communities are to be successful in addressing health disparity, specific training in these skills will need to be developed and made available., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Purpose: This investigation was undertaken to define the barriers to Indigenous peoples participating in biobanking and genomic research., Methods: A literature review was conducted to identify studies reporting on the experience of Indigenous peoples with biobanking, tissue banking, and genomic research. Studies pertaining to organ transplantation or blood donation for transfusion were excluded. The databases searched were MEDLINE, EMBASE, PubMed, Web of Science, and Google Scholar, with all literature available until the search date of June 1, 2018, included. The reference lists of all included papers, as well as related review articles, were manually searched to identify additional relevant studies. An inductive approach was used to identify common themes., Results: Seventeen publications discussed the experiences of New Zealand Māori (n = 2), Aboriginal and Torres Strait Islanders (n = 3), Native Hawaiian (n = 4), Native Alaskan (n = 2), American First Nation (n = 2), or multiple ethnicities (n = 4). Across all Indigenous peoples, four themes emerged: land, ancestors, culture, and bodily substances are powerfully interconnected and can act on each other; tissue and blood can provide important information (both Western and traditional) about a person; the ownership of specimens-custodians, trustees, or guardians; and the beneficence of the researchers and research team., Conclusion: Indigenous communities, like Western populations, are concerned with issues pertaining to handling, treatment, and ownership of tissue as well as knowledge gained from specimen analysis. Unlike many Western populations, Indigenous communities have retained a strong sense of cultural connection to ancestors and traditional lands and view biologic specimens as inseparable from these things.

Aim: As part of a project developing cancer service capability, the National Health Service (NHS) Cancer patient experience survey was used to assess the currently available services at Waitemata District Health Board (WDHB)., Methods: Patients presenting with cancer to WDHB in the previous 12 months were mailed a copy of the survey, to the initial cohort in 2013 and to the second in 2015. Results were compared between survey periods and with the 2015 NHS Cancer Patient Experience Survey., Results: In 2013, 329 patients completed the survey while 319 responded in 2015. Over 90% of patients classed their experience as good or excellent in both survey periods and comparison showed significant overall improvement (p=0.001) in patient experience between 2013 and 2015. Overall, WDHB benchmarked with the NHS experience but the NHS performed better than WDHB in cancer nurse specialist contact for ongoing support and information related to eligibility for financial assistance., Conclusion: The results of these confirm that the NHS Cancer Patient Experience Survey provides meaningful data within New Zealand and that WDHB cancer patient experience has improved over the survey period. This data has assisted WDHB in prioritising patient information resources and treatment planning in developing services., Competing Interests: Nil.

New Zealand Māori have a considerably higher incidence of gastric cancer compared to non-Māori, and are one of the few populations worldwide with a higher prevalence of diffuse-type disease. Pathogenic germline CDH1 mutations are causative of hereditary diffuse gastric cancer, a cancer predisposition syndrome primarily characterised by an extreme lifetime risk of developing diffuse gastric cancer. Pathogenic CDH1 mutations are well described in Māori families in New Zealand. However, the contribution of these mutations to the high incidence of gastric cancer is unknown. We have used next-generation sequencing, Sanger sequencing, and Multiplex Ligation-dependent Probe Amplification to examine germline CDH1 in an unselected series of 94 Māori gastric cancer patients and 200 healthy matched controls. Overall, 18% of all cases, 34% of cases diagnosed with diffuse-type gastric cancer, and 67% of cases diagnosed aged less than 45 years carried pathogenic CDH1 mutations. After adjusting for the effect of screening known HDGC families, we estimate that 6% of all advanced gastric cancers and 13% of all advanced diffuse-type gastric cancers would carry germline CDH1 mutations. Our results demonstrate that germline CDH1 mutations are a significant contributor to the high frequency of diffuse gastric cancer in New Zealand Māori.