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Purpose. Cancer survivors are at risk of comorbidities, with those in non-metropolitan areas being particularly susceptible. Survivors identify unique barriers and supports to facilitate change, which may differ across survivors’ geographical classification. Methods. Survivors from metropolitan (n = 103) and non-metropolitan (n = 80) areas in Australia described barriers and suggested supports for physical activity and dietary change via open-ended survey items. Responses underwent thematic analysis. Results. Survivors’ barriers were primarily motivational and social. Survivors suggested change supports that corresponded with barriers, encompassing accountability, information from health professionals, and supportive social environments. Non-metropolitan survivors expressed logistical barriers and desired health professionals’ support. Conclusion. Novel insights have revealed the importance of social influences in supporting behavioural change. As poor motivation was a primary barrier across health behaviours and locations, programs may focus on strengthening commitment for change and harnessing the value of local support networks.

Background The prognostic value of tumor‐associated dendritic cells (DC) in colon cancer remains poorly understood. This may be in part due to the interchangeable expression of immunostimulatory and immunoinhibitory molecules on DC. Here we investigated the prognostic impact of CD11c+ DC co–expressing the immunoinhibitory molecule PD‐L1 and their spatial relationship with CD8+ T‐cells in patients treated for stage III colon cancer. Methods Tissue microarrays containing representative cores of central tumor, leading edge, and adjacent normal tissue from 221 patients with stage III colon cancer were immunostained for CD8, CD11c, PD‐L1, and cytokeratin using immunofluorescent probes. Cells were quantified using StrataQuest digital image analysis software, with intratumoral and stromal regions analyzed separately. Kaplan‐Meier estimates and Cox regression were used to assess survival. Results Intratumoral CD8+ cell density (HR = .52, 95% confidence interval [CI] .33‐.83, P = .007), stromal CD11c+ cell density (HR = .52, 95% CI .33‐.83, P = .006), intratumoral CD11c+PD‐L1+ cell density (HR = .57, 95% CI .35‐.92, P = .021), and stromal CD11c+PD‐L1+ cell density (HR = .48, 95% CI .30‐.77, P = .003) on leading‐edge cores were all significantly associated with good survival. CD8+ cell density was positively correlated with both CD11c+ cell density and CD11c+PD‐L1+ cell density in tumor epithelium and stromal compartments. Conclusion Here we showed that PD‐L1‐expressing DC in the tumor microenvironment are associated with improved survival in stage III colon cancer and likely reflect an immunologically “hot” tumor microenvironment. Further investigation into the expression of immunomodulatory molecules by tumor‐associated DC may help to further elucidate their prognostic value., In this study, using immunofluorescence analysis of fixed surgical samples, we demonstrate that PD‐L1 expressing dendritic cells are associated with good prognosis in stage III colon cancer. However, densities of PD‐L1 expressing dendritic cells were correlated to CD8 T cell density, indicating that they may represent an immunologically “hot” tumor microenvironment. Further investigation into the expression of immunomodulatory molecules by DC is required.

Background Postoperative mortality after colorectal cancer surgery varies across hospitals and countries. The aim of this study was to test the Association of Coloproctologists of Great Britain and Ireland (ACPGBI) models as predictors of 30‐day mortality in an Australian cohort. Methods Data from patients who underwent surgery in six hospitals between 1996 and 2015 (CRC data set) were reviewed to test ACPGBI models, and patients from 79 hospitals in the Bi‐National Colorectal Cancer Audit between 2007 and 2016 (BCCA data set) were analysed to validate model performance. Recalibrated models based on ACPGBI risk models were developed, tested and validated on a data set of Australasian patients. Results Of 18 752 patients observed during the study, 6727 (CRC data set) and 3814 (BCCA data set) were analysed. The 30‐day mortality rate was 1·1 and 3·5 per cent in the CRC and BCCA data sets respectively. Both the original and revised ACPGBI models overestimated 30‐day mortality for the CRC data set (observed to expected (O/E) ratio 0·17 and 0·21 respectively). Their ability to correctly predict mortality risk was poor (P, The aim was to test the Association of Coloproctologists of Great Britain and Ireland (ACPGBI) original (2003) and revised (2010) models as predictors of 30‐day mortality in an Australian patient cohort, and then recalibrate these models using data from Australian patients. This study included 10 541 patients treated over a 20‐year interval in Australia and New Zealand. The ACPGBI models overestimated 30‐day mortality, and so both ACPGBI models should be used with caution in Australia. Mortality risk prediction after colorectal surgery

Cancer survivors are at risk of comorbidities and mortality, and those living outside of metropolitan areas are particularly susceptible given poorer socioeconomic, health and support resources. As engagement in health behaviours is affected by participants’ autonomous motives, investigation of the motives of cancer survivors in metropolitan and non-metropolitan areas could elucidate the values and reasons for practising health behaviours, allowing programs to be tailored to these motives. Metropolitan (n = 103) and non-metropolitan (n = 80) Australian cancer survivors completed a survey item by describing their motives for physical activity and healthy diet change. Inductive thematic analysis of responses was performed to establish themes across health behaviour motives. Analyses revealed four themes: to be able to, longevity, psychological health and appearance. Survivors primarily referred to being able to enjoy family, leisure activities, travel and staying independent, with these motives often linked to longevity. Motives were similar across locations; however, those in non-metropolitan locations reported continuation of work and pain relief more frequently. Female survivors more often reported weight loss. A predominant motive for health behaviour change in cancer survivors across geographical location was the ability to enjoy family and engage in leisure and work activities. Programs aiming to promote health behaviours in cancer survivors might consider framing interventions accordingly by emphasizing benefits of longevity and maintaining independence.

BACKGROUND Recent evidence supports the safety of early reversal of a temporary stoma, within 14 days of construction. The aim of this systematic review and meta-analysis was to evaluate the post-operative morbidity and overall feasibility of early stoma reversal. METHODS Medline and Cochrane databases were searched for studies up to June 2019 that investigated the outcomes of early stoma reversal (EC, defined as closure ≤14 days from the index operation) versus late stoma reversal (LC, ≥8 weeks from the index operation). Meta-analysis was performed on the respective rates of post-operative morbidity, anastomotic leak, wound infection, bleeding, sepsis, small bowel obstruction and ileus. RESULTS Nine studies were included (667 patients analysed). Meta-analysis showed no significant difference in the post-operative morbidity rate, anastomotic leak rate, rates of small bowel obstruction, bleeding and ileus between EC and LC. However, the wound infection rate was significantly higher after EC than LC; relative difference 0.10 (95% confidence interval 0.00-0.19, P = 0.047). The stoma-related complication rate was significantly higher after LC than EC; relative difference -0.28 (95% confidence interval -0.45 to -0.11, P = 0.001). CONCLUSION The concept of early stoma reversal is appealing, and this meta-analysis confirms the safety of early stoma closure with an associated reduction in stoma-related complications despite higher wound infection rates. However, the results need to be interpreted with caution due to the heterogeneity of the studies included, especially in respect of the definition of complications that were used. Further well-designed prospective studies are required prior to confident adoption of early stoma closure into clinical practice.

Background Bariatric surgery is the strongest evidence-based treatment available for obesity, but the long-term morbidity and durability of these procedures is being increasingly scrutinized. Objective To report the incidence, timing, indications, and risk factors for bariatric reoperations. Setting A state-wide, multicenter, retrospective study. Methods Using the Western Australian Department of Health Data Linkage Unit, all patients undergoing an index bariatric procedure where identified across a 10-year period (2007–2016). Results Of 24,766 patients who underwent bariatric surgery, 5001 patients (20.2%) required at least 1 bariatric reoperation. The 5-yearly rates were 19.6% (95% confidence interval [CI], 19.0%–20.2%) for a first revision, 58.2% (95%CI, 56.6%–59.8%) for a subsequent second revision, 38.3% (95%CI, 35.4%–41.2%) for a subsequent third revision, and 45.2% (95%CI, 39.9%–50.5%) for a subsequent fourth revision. Surgical complications (67.4%) were the main indication for any bariatric reoperation ahead of weight-related causes (32.6%). In a Cox regression analysis, being younger, female, without private health insurance, and having a gastric band as the initial bariatric procedure were all significant risk factors for bariatric reoperations. Compared with bariatric patients needing only an index procedure, patients requiring bariatric reoperations also had higher postoperative incidence rate ratios of endoscopic (incidence rate ratio 2.4; 95%CI, 2.3–2.5) and body contouring (incidence rate ratio 3.8; 95%CI, 3.5–4.1) procedures. Conclusions Patients undergoing bariatric surgery had a high incidence of bariatric reoperations, predominantly for surgical complications. Of those patients who required bariatric reoperations, there were additional high rates of recurrent bariatric surgery, postoperative endoscopy, and body contouring procedures.

Background Various surgical options for rectal prolapse are available but none have been shown to be clearly superior. The aims of this study were to investigate the long-term recurrence rate of a variety of surgical approaches, their associated morbidities and the types of reoperation used to treat recurrence. Methods A retrospective analysis was performed of all cases of rectal prolapse surgery within one colorectal surgical unit between January 2000 and June 2017. Abdominal approaches consisted of rectopexy (RP) and resection rectopexy (RRP); perineal approaches included perineal rectosigmoidectomy (PR) and Delorme's repair (DR). Complications were graded according to the Clavien-Dindo classification. The median follow-up was 4.5 years (interquartile range 1.5-10.1, maximum 16.5). Statistical analysis was performed using Kaplan-Meier to determine recurrence rates. Results A total of 157 patients were included in the study. The numbers for each procedure were: DR (n = 55), RRP (n = 44), RP (n = 38) and PR (n = 20). The majority were females (94%). The perineal group were significantly older than the abdominal group (80 versus 67 years, P = 0.0001). At 5 years, the recurrence rates were 52%, 30%, 5% and 3% for DR, PR, RP and RRP, respectively. Morbidity was highest in PR (20%) followed by RRP (18%), RP (16%) and DR (7%) (n.s.). The overall morbidity rates for perineal group and abdominal group were 10.7% and 17.1%, respectively (n.s.). Conclusion Abdominal approaches have a significantly lower recurrence rate at 5 years but tend to be associated with higher morbidity.

Cancer survivors are at risk of comorbidities and mortality, and those living outside of metropolitan areas are particularly susceptible given poorer socioeconomic, health and support resources. As engagement in health behaviours is affected by participants' autonomous motives, investigation of the motives of cancer survivors in metropolitan and non-metropolitan areas could elucidate the values and reasons for practising health behaviours, allowing programs to be tailored to these motives.Metropolitan (n = 103) and non-metropolitan (n = 80) Australian cancer survivors completed a survey item by describing their motives for physical activity and healthy diet change. Inductive thematic analysis of responses was performed to establish themes across health behaviour motives.Analyses revealed four themes: to be able to, longevity, psychological health and appearance. Survivors primarily referred to being able to enjoy family, leisure activities, travel and staying independent, with these motives often linked to longevity. Motives were similar across locations; however, those in non-metropolitan locations reported continuation of work and pain relief more frequently. Female survivors more often reported weight loss.A predominant motive for health behaviour change in cancer survivors across geographical location was the ability to enjoy family and engage in leisure and work activities. Programs aiming to promote health behaviours in cancer survivors might consider framing interventions accordingly by emphasizing benefits of longevity and maintaining independence.

OBJECTIVE: Interventions to increase physical activity (PA) in cancer survivors have often adopted a 'one-size-fits-all' approach, and may benefit from being tailored to psychological constructs associated with behavior. The study objective was to investigate the exercise preferences and psychological constructs related to PA among cancer survivors. METHODS: Post-treatment colorectal, endometrial, and breast cancer survivors (n=183) living in metropolitan and non-metropolitan areas completed survey measures of PA, exercise preferences, attitudes, self-efficacy, perceived behavioral control (PBC), and intention toward PA. RESULTS: A structural equation model with adequate fit and quality indices revealed that instrumental attitude and self-efficacy were related to PA intention. Intention was related to behavior and mediated the relationship between self-efficacy and behavior. Preferred exercise intensity was related to self-efficacy, PBC, attitudes, and intention, while preferred exercise company was related to self-efficacy and PBC. Participants preferred moderate-intensity PA (71%), specifically self-paced (52%) walking (65%) in an outdoor environment (58%). CONCLUSIONS: Since instrumental attitude and self-efficacy were associated with PA, incorporating persuasive communications targeting attitudes in PA interventions may promote PA participation. As cancer survivors who prefer low-intensity exercise and exercising with others report lower self-efficacy and PBC, interventions targeting confidence and successful experience in this group may also be warranted. This article is protected by copyright. All rights reserved.

SOX2 (sex-determining region-Y homeobox-2) is a transcription factor essential for the maintenance of pluripotency and is also associated with stem-cell-like properties in preclinical cancer models. Our previous study on a cohort of stage III colon cancer patients demonstrated high SOX2+ cell densities were associated with poor prognosis. However, most patients were treated with adjuvant chemotherapy so the prognostic value of SOX2 could not be assessed independently from its value as a predictive marker for non-response to chemotherapy. This study aimed to assess whether SOX2 was a true prognostic marker or a marker for chemotherapy response in a historical cohort of patients, a high proportion of whom were chemotherapy-naïve. SOX2 immunostaining was performed on tissue micro-arrays containing tumor cores from 797 patients with stage II and III colorectal cancer. SOX2+ cell densities were then quantified with StrataQuest digital image analysis software. Overall survival was assessed using Kaplan–Meier estimates and Cox regression. It was found that high SOX2+ cell densities were not associated with poor overall survival. Furthermore, all patients had a significant improvement in survival after 5-fluorouracil (5-FU) treatment, irrespective of their SOX2+ cell density. Therefore, SOX2+ cell densities were not associated with prognosis or chemotherapy benefit in this study. This is in contrast to our previous study, in which most patients received oxaliplatin as part of their treatment, in addition to 5-FU. This suggests SOX2 may predict response to oxaliplatin treatment, but not 5-FU.

Background: To develop a risk-adjustment model for unplanned return to theatre (URTT) outcomes following colorectal surgeries in Australia and New Zealand hospitals and apply top-down and bottom-up statistical process control methods for fair comparison of hospitals and surgeons’ URTT rates. Methods: We analysed URTT outcomes from hospitals contributing data to the Bi-National Colorectal Cancer Audit clinical registry between 2007 and 2016. Preoperative and intraoperative covariates were considered for risk adjustment. A risk-adjusted rate funnel plot was prepared for between-hospital comparisons and identification of outlying hospitals with unusually high rates of URTT. Cumulative observed-minus-expected charts with cumulative sum signals were then presented for surgeons within an outlying hospital. Results: The study included 15 134 patients and 166 surgeons across 70 hospitals. The weighted average URTT rate was 5.2%. The risk-adjustment model identified 12 preoperative and intraoperative variables that significantly raise the risk of URTT: male sex, American Society of Anesthesiologists score, emergency admissions, conversion entry, left hemicolectomy, total colectomy, proctocolectomy, lower anterior resection, ultra-low anterior resection, abdominoperineal resection, organ resection and excess lymph nodes harvested. Right hemicolectomy significantly reduced risk of URTT. URTT rates were not found to significantly vary across seniority of operator; however, comparisons were limited by lack of data on junior operators. The funnel plot identified five hospitals as ‘possible outliers’ and hospital T was identified as a ‘definite outlier’. The cumulative observed-minus-expected charts with cumulative sum signals showed that within hospital T, one surgeon among three had a particularly bad run of URTTs. Conclusion: Feedback from aggregated URTT outcomes using a risk-adjusted rate funnel plot is enhanced when follow-up examination of outlying hospitals is conducted with concurrent application of cumulative observed-minus-expected charts with cumulative sum signals.

BACKGROUND Anal squamous cell carcinoma (SCC) is a rare malignancy. The purpose of this study was to review a single institution's experience. METHODS All patients with anal SCC from St John of God Subiaco Hospital database were identified over a 10-year period (2006-2016). Patients with stage 1 anal verge tumours underwent wide local excision, all remaining patients were offered chemoradiation (CRT) as an initial treatment modality (a fluorouracil-based regimen in conjunction with mitomycin). Outcomes included recurrence, overall survival and survival following salvage surgery. RESULTS Forty-seven patients were identified. Median age was 60 years and median follow-up was 2.73 years. Five-year rates of recurrence and overall survival were 35.8% (95% confidence interval (CI) 23.2-52.4%) and 65.4% (95% CI 47.0-78.7%), respectively. Locoregional failure occurred most commonly at the primary site. Eight patients underwent salvage abdominoperineal resection for persistent or recurrent disease, and four of these patients died within 5 years. CONCLUSION CRT is a proven and reasonable effective approach in managing anal cancer. Observed recurrence and overall survival rates in this study resemble the published data. Despite newer methods of treatment being investigated, the treatment for anal SCC has not significantly changed in the past four decades and novel approaches are needed to further improve outcomes.

Background/Objective: Colorectal and gynecologic cancer survivors are at cardiovascular risk due to comorbidities and sedentary behaviour, warranting a feasible intervention to increase physical activity. The Health Action Process Approach (HAPA) is a promising theoretical framework for health behaviour change, and wearable physical activity trackers offer a novel means of self-monitoring physical activity for cancer survivors. Method: Sixty-eight survivors of colorectal and gynecologic cancer will be randomised into 12-week intervention and control groups. Intervention group participants will receive: a Fitbit Alta™ to monitor physical activity, HAPA-based group sessions, booklet, and support phone-call. Participants in the control group will only receive the HAPA-based booklet. Physical activity (using accelerometers), blood pressure, BMI, and HAPA constructs will be assessed at baseline, 12-weeks (post-intervention) and 24-weeks (follow-up). Data analysis will use the Group x Time interaction from a General Linear Mixed Model analysis. Conclusions: Physical activity interventions that are acceptable and have robust theoretical underpinnings show promise for improving the health of cancer survivors.

Background Infusional 5-fluorouracil (5-FU) has been the standard radiation sensitizer in patients undergoing preoperative long-course chemoradiotherapy (CRT) for locally advanced rectal cancer in Australia. Capecitabine (Xeloda) is an oral 5-FU prodrug of comparable pharmacodynamic activity, currently preferred in place of 5-FU infusion, its established counterpart in neoadjuvant CRT for rectal cancer. The few studies quantifying pathological complete response (pCR) of Xeloda versus 5-FU have produced inconsistent results. We reviewed our own data to determine if the rates of pCR of oral capecitabine were non-inferior to intravenous 5-FU in patients undergoing neoadjuvant CRT for rectal cancer. Methods A retrospective study was performed from a prospectively kept database. Four hundred and fifty-two patients received preoperative CRT from January 2006 to January 2016. Pelvic radiotherapy was delivered concurrently with capecitabine (n = 42) or infusional 5-FU (n = 341). The remaining received different chemotherapy regimens. Surgery was performed 6-12 weeks of CRT completion. Pathological responses were assessed using Dworak regression grading score (0-4). Clinical outcomes were evaluated in terms of local control and recurrence-free survival. Results The proportion of patients who had a tumour regression score of 4 (pCR) after CRT was 4/42 (9.5%) in the capecitabine group and 71/341 (20%) in the infusional 5-FU group (P = 0.082). pCR was an independent predictor for survival in this group of patients (hazard ratio: 0.002, P = 0.0001, 95% confidence interval: 0.0001-0.027). Conclusion The use of capecitabine as neoadjuvant chemotherapy in patients with rectal cancer was associated with a reduced rate of pCR. However this difference did not achieve statistical significance.

BACKGROUND To assess pattern distribution and prognosis of the three anatomical entities of metastatic colorectal cancer, and influence of treatment of metastases on survival. METHODS Patients presenting with stage IV colorectal cancer (synchronous group), or who developed metastatic recurrence (metachronous group) after initial curative treatment between January 2005 and August 2015 were reviewed. Right sided (cecum to transverse colon), left sided (splenic flexure to sigmoid colon) and rectal cancers were identified. Distribution of metastases were noted as hepatic, lung or peritoneal. RESULTS Of 374 patients, 276 were synchronous, 98 were metachronous. Metachronous group had a better 3-year survival (54%, 95% CI: 42-64 versus 33%, 95% CI: 27-39, log rank P = 0.0038). There were equal numbers of right (n = 119), left (n = 115) and rectal cancers (n = 140). Rectal cancers had a higher metastatic recurrence, yet demonstrated better 3-year survival (right colon 45%, 95% CI: 19-67, left colon 49%, 95% CI: 27-68, rectum 59%, 95% CI: 42-72, P = 0.39) due to higher proportions of metachronous patients undergoing treatment for metastases (40 versus 14%). Over half of all organ metastases spread to liver, with equal distribution from all three anatomical groups. Rectal cancers showed highest preponderance for lung metastases. CONCLUSION Rectal cancers have a higher chance of recurring, with a higher metastatic rate to the lung, yet demonstrate better survival outcomes in metastatic colorectal cancer, reflecting the benefit of intervention for metastases.

// Melanie J. McCoy 1, 4 , Chris Hemmings 2, 3 , Chidozie C. Anyaegbu 1 , Stephanie J. Austin 1, 3 , Tracey F. Lee-Pullen 1, 3 , Timothy J. Miller 1, 3 , Max K. Bulsara 5 , Nikolajs Zeps 1, 3 , Anna K. Nowak 4, 6 , Richard A. Lake 4 , Cameron F. Platell 1, 3 1 Colorectal Research Unit, St John of God Subiaco Hospital, Subiaco, WA, 6008, Australia 2 Department of Anatomic Pathology, St John of God Pathology, Wembley, WA, 6014, Australia 3 School of Surgery, University of Western Australia, Crawley, WA, 6009, Australia 4 School of Medicine and Pharmacology, University of Western Australia, Crawley, WA, 6009, Australia 5 Institute for Health Research, University of Notre Dame, Fremantle, WA, 6959, Australia 6 Department of Medical Oncology, Sir Charles Gairdner Hospital, Nedlands, WA, 6009, Australia Correspondence to: Melanie McCoy, email: melanie.mccoy@uwa.edu.au Keywords: rectal cancer, regulatory T cells, radiotherapy, chemotherapy, treatment response Received: September 13, 2016 Accepted: January 07, 2017 Published: February 03, 2017 ABSTRACT Neoadjuvant (preoperative) chemoradiotherapy (CRT) decreases the risk of rectal cancer recurrence and reduces tumour volume prior to surgery. However, response to CRT varies considerably between individuals and factors associated with response are poorly understood. Foxp3 + regulatory T cells (Tregs) inhibit anti-tumour immunity and may limit any response to chemotherapy and radiotherapy. We have previously reported that a low density of Tregs in the tumour stroma following neoadjuvant CRT for rectal cancer is associated with improved tumour regression. Here we have examined the association between Treg density in pre-treatment diagnostic biopsy specimens and treatment response, in this same patient cohort. We aimed to determine whether pre-treatment tumour-infiltrating Treg density predicts subsequent response to neoadjuvant CRT. Foxp3 + , CD8 + and CD3 + cell densities in biopsy samples from 106 patients were assessed by standard immunohistochemistry (IHC) and evaluated for their association with tumour regression grade and survival. We found no association between the density of any T cell subset pre-treatment and clinical outcome, indicating that tumour-infiltrating Treg density does not predict response to neoadjuvant CRT in rectal cancer. Taken together with the findings of the previous study, these data suggest that in the context of neoadjuvant CRT for rectal cancer, the impact of chemotherapy and/or radiotherapy on anti-tumour immunity may be more important than the state of the pre-existing local immune response.

Primary local excision (PLE) for early rectal cancers is associated with decreased surgical morbidity and mortality compared with major resection (MR). However, it is thought to be associated with poorer oncological outcomes. There is a paucity of data regarding PLE within the Australasian population. We present comparative post-operative and survival outcomes for stage 1 rectal cancers treated with PLE or MR from three Western Australian hospitals. A retrospective analysis was performed on a prospectively maintained database of patients undergoing PLE or MR for stage 1 rectal cancers between February 1996 and May 2019. Of the 533 patients, 81 underwent PLE. Median post-operative admission was shorter for those undergoing PLE, with no significant difference in post-operative complication rate. Five-year overall survival was greater following MR (89.6% CI 86.1–92.3) compared with PLE (84.6% CI 73.8–91.2; p = 0.0003). There was no significant difference in 5-year cancer-specific survival (MR, 94.4% CI 91.5–96.3; PLE, 95.3% CI 86.0–98.5; p = 0.98) or 5-year disease-free survival (MR, 92.3% CI 89.1–94.7; PLE, 89.1% CI 78.5–94.7; p = 0.36). Local excision provided poorer local tumour control with an inferior 5-year local recurrence rate (MR, 2.16% CI 1.08–4.28; PLE, 10.9% CI 5.30–21.6; p = 0.0002). After controlling for confounders, PLE was significantly associated with worse local recurrence but did not significantly impact overall survival, cancer-specific survival, overall recurrence, or metastatic recurrence. Local excision of early rectal cancer remains a viable alternative, in those unwilling or unable to undergo MR. Patients should be informed that while PLE is associated with poorer local pelvic control, this does not translate to worse survival.

Background Pilonidal sinus disease is a common surgical disorder for which a clearly superior corrective operation remains elusive. Recurrence after surgery requiring re-operation is a frequent outcome. This retrospective study examines healing rates, recurrence rates and time to healing of a minimalist approach - employing deroofing of tracks, curettage and minimal skin excision - at one centre over the last decade. Methods The results of all minimal excision pilonidal sinus operations performed from 2005 to 2018 by two surgeons at one centre have been analysed retrospectively. Ethics approval for this study was granted by the St John of God Health Care Human Research Ethics Committee on 11 June 2018. Results A total of 84 patients were included in this study with 19 females and 65 males. The median age at operation was 22 years. Of the 84 total patients, 78 achieved primary healing (93%) with an average healing time of 55 days. Of those that healed, seven recurred with an average time to recurrence of 812 days. Conclusion In our study, minimal excision management of pilonidal sinus disease achieved primary healing in 93% with an average healing time of 55 days and a recurrence rate of 8%. These outcomes are similar, but not significantly inferior, to those reported for other surgical modalities of management. Given this, we suggest less invasive management may be a preferable first surgical option given smaller surgical intervention for similar outcomes.

Importance Obesity is associated with an increased prevalence of psychiatric disorders. The association of bariatric surgery with mental health outcomes is poorly understood. Objective To investigate the association of bariatric surgery with the incidence of outpatient, emergency department (ED), and inpatient mental health service use. Design, Setting, and Participants This statewide, mirror-image, longitudinal cohort study used data from Western Australian Department of Health Data Linkage Branch records from all patients undergoing index (ie, first) bariatric surgery in Western Australia over a 10-year period (January 2007-December 2016), with mean (SD) follow-up periods of 10.2 (2.9) years before and 5.2 (2.9) years after index bariatric surgery. The data analysis was performed between November 2018 and March 2019. Exposures Index bariatric surgery. Main Outcomes and Measures The incidence and predictors for mental health presentations, deliberate self-harm, and suicide in association with the timing of bariatric surgery. Results A total of 24 766 patients underwent index bariatric surgery; of these, the mean (SD) age was 42.5 (11.7) years and 19 144 (77.3%) were women. Use of at least 1 mental health service occurred in 3976 patients (16.1%), with 1401 patients (35.2%) presenting only before surgery, 1025 (25.8%) presenting before and after surgery, and 1550 patients (39.0%) presenting only after surgery. There was an increase in psychiatric illness presentations after bariatric surgery (outpatient clinic attendance: incidence rate ratio [IRR], 2.3; 95% CI, 2.3-2.4; ED attendance: IRR, 3.0; 95% CI, 2.8-3.2; psychiatric hospitalization: IRR, 3.0; 95% CI, 2.8-3.1). There was also a 5-fold increase in deliberate self-harm presentations to an ED after surgery (IRR, 4.7; 95% CI, 3.8-5.7), with 25 of 261 postoperatives deaths (9.6%) due to suicide. Complications after bariatric surgery requiring further surgical intervention and a history of mental health service provision before surgery were the most important associations with subsequent mental health presentations after surgery. Deliberate self-harm and mental and behavioral disorders due to psychoactive substance use before bariatric surgery were the main associations with subsequent deliberate self-harm or suicide after surgery. Conclusions and Relevance We observed an increase in mental health service presentations after bariatric surgery, particularly among those who had prior psychiatric illnesses or developed surgical complications requiring further surgery. These findings caution the hypothesis that weight reduction by bariatric surgery will improve mental health in patients with obesity.

IntroductionPhysically active cancer survivors have substantially less cancer recurrence and improved survival compared with those who are inactive. However, the majority of survivors (70%–90%) are not meeting the physical activity (PA) guidelines. There are also significant geographic inequalities in cancer survival with poorer survival rates for the third of Australians who live in non-metropolitan areas compared with those living in major cities. The primary objective of the trial is to increase moderate-to-vigorous PA (MVPA) among cancer survivors living in regional and remote Western Australia. Secondary objectives are to reduce sedentary behaviour and in conjunction with increased PA, improve quality of life (QoL) in non-metropolitan survivors. Tertiary objectives are to assess the effectiveness of the health action process approach (HAPA) model variables, on which the intervention is based, to predict change in MVPA.Methods and analysisEighty-six cancer survivors will be randomised into either the intervention or control group. Intervention group participants will receive a Fitbit and up to six telephone health-coaching sessions. MVPA (using Actigraph), QoL and psychological variables (based on the HAPA model via questionnaire) will be assessed at baseline, 12 weeks (end of intervention) and 24 weeks (end of follow-up). A general linear mixed model will be used to assess the effectiveness of the intervention.Ethics and disseminationEthics approval has been obtained from St John of God Hospital Subiaco (HREC/#1201). We plan to submit a manuscript of the results to a peer-reviewed journal. Results will be presented at conferences, community and consumer forums and hospital research conferences.Trial registration numberACTRN12618001743257; pre-results, U1111-1222-5698

Background Australia has one of the highest rates of colorectal cancer worldwide. Despite technological advances in colorectal surgery, anastomotic leaks (ALs) continue to cause significant morbidity and mortality. Ultra-low anterior resections (ULARs) carry the highest prevalence of AL. The aim of the study is to evaluate the incidence, treatment and consequences of AL following ULAR for colorectal cancer from a single colorectal unit. Methods This is a retrospective evaluation of prospectively collected data on patients undergoing ULAR following rectal cancer. The main end points include the prevalence and management of AL following initial operation and the morbidity, re-operation and mortality rates associated with AL. A stepwise logistic regression analysis and a multivariate analysis were performed to identify independent risk factors. Results A total of 467 patients underwent an ULAR. There were 32 (6.8%) ALs. Average follow-up time was 79 months. There were five subclinical leaks and only one (20%) required intervention. The overall survival rate at 5 years was 80% (95% confidence interval 58-91). On univariate analysis male sex was a risk factor for AL (P = 0.03). On multivariate analysis patients who had a complete response to radiotherapy were more likely to have a leak than the patients who had no radiotherapy (grade 4, odds ratio 4.0, 95% confidence interval 1.4-10.9, P = 0.01). Conclusion This study has highlighted the relevance of subclinical leaks and their associated morbidity. It identified that radiotherapy a risk factor for AL, but the response to radiotherapy is an even better predictor of leakage.

Analysis of immunohistochemical expression is often a subjective and semiquantitative process that can lead to the inconsistent reporting of results. To assess the effect that region selection and quantification method have on results, five different cancer stem cell markers were used in this study to compare tissue scoring with digital analysis methods that used three different tissue annotation methods. Samples of tumour and normal mucosa were used from 10 consecutive stage II colon cancer patients and stained for the putative cancer stem cell markers ALDH1, CD44v6, CD133, Lgr5 and SOX2. Tissue scoring was found to have considerably different results to digital analysis with the three different digital methods harbouring concordant results overall. However, SOX2 on normal tissue and CD133 on tumour and normal tissue produced discordant results which could be attributed to the different regions of tissue that were analysed. It is important that quantification method and selection of analysis areas are considered as part of study design to ensure that reproducible and consistent results are reported in the literature.

Background: Lifestyle factors including inadequate physical activity may contribute to increased risk of developing cardiovascular disease in colorectal cancer survivors. Identification of the barriers to physical activity is important for forming an evidence base of factors to target in future physical activity programs aimed at improving cardiovascular health in this population. Methods: Colorectal cancer survivors (N = 24) from St. John of God Subiaco Hospital participated in semi-structured interviews about their current physical activity behaviors and perceived barriers to physical activity. Results: Inductive thematic analysis of interviews revealed 5 overarching themes relating to barriers to physical activity: psychological barriers, environmental barriers, knowledge of guidelines, lack of practitioner support, and energy/age barriers. Conclusions: Novel findings revealed participants' dependence on practitioner support, including a reliance on practitioners to recommend lifestyle change. Survivors also revealed that regular checkups to monitor cardiovascular risk replaced the need for healthy lifestyle changes. Implications: With survivors holding the advice of clinicians in high regard, an opportunity exists for clinicians to facilitate lifestyle change. Health care professionals such as nurses can implement motivational strategies and provide additional health information during follow-up visits, to ensure long-term adherence. Individuals who reported psychological, motivational, and environmental barriers may benefit from interventions to improve self-regulation, planning, and problem-solving skills.

Background In the last decade, there has been a significant increase in interest for public reporting of outcome data and performance comparison across institutions and surgeons. This study aims at comparing postoperative mortality after colorectal cancer surgery across units and individual consultants in Australia and New Zealand using funnel plots. Methods The Bi-National Colorectal Cancer Audit database was used. Unadjusted and adjusted funnel plots of inpatient mortality were constructed. Risk adjustment was based upon multivariable logistic regression models using purposeful covariate selection. Results A total of 10 008 patients undergoing surgery for colorectal cancer from 56 surgical units and 90 consultants were identified. Overall inpatient mortality was 1.51%, corresponding to 1.1% for elective and 3.9% for urgent cases. Logistic regression identified age, American Society of Anesthesiologists score, urgent surgery and open surgery to be independently associated with inpatient mortality. Unadjusted and adjusted funnel plot analysis identified three (5.3%) units exceeding the inner limit and none exceeding the outer limit. Six (6.6%) consultants had inpatient mortality between the upper inner and outer limits and one (1.1%) between the inferior inner and outer limits. Upon adjustment, seven (7.7%) consultants had inpatient mortality between the inner and outer limit. Potential limitations of this study include: residual confounding being responsible for the association of open surgery and mortality; incomplete case-mix adjustment resulting in outlier identification; and bias towards inclusion of larger institutions. Conclusion Mortality figures in Australia and New Zealand are comparable to recently reported international data. The vast majority of units and consultants are performing within the expected boundaries.

Purpose The purpose of the study was to explore colorectal cancer survivors' health perceptions following cessation of active treatment for cancer and to explore the factors influencing participation in health-promoting behaviors that may help reduce cardiovascular disease risk. Methods Face-to-face interviews were conducted with participants that had completed active treatment for cancer within the previous 2 years. Participants were colorectal cancer survivors (N = 24, men = 11, women = 13, M age = 69.38 years, SD = 4.19) recruited from a private hospital in Perth, Australia on the basis that they had existing morbidities that put them at increased risk of cardiovascular disease. Interview transcripts were analyzed using thematic analysis. Results Five main themes emerged: back to normal; the pleasures in life: ‘is it worth it?’; beliefs about health behavior; skepticism of eating guidelines; and lack of motivation. The majority of participants felt they were in good health and had made a full recovery. Participants questioned whether it was worth changing their lifestyle given their life stage and referred to the desire to enjoy life. Lay health beliefs, skepticism of eating guidelines, and a lack of motivation were barriers to change. Conclusions Interventions should target lay beliefs and skepticism in relation to health behaviors in order to reinforce the importance and value of participating in health-related behavior. Implications for Cancer Survivors Findings may inform the development of effective, patient-centered interventions that target lay health beliefs and build motivation for health behavior change. Copyright © 2016 John Wiley & Sons, Ltd.

The use of multi-colour immunofluorescence (IF) for immunophenotyping in formalin-fixed paraffin-embedded tissue sections is gaining popularity worldwide. This technique allows for the simultaneous detection of multiple markers on the same tissue section, thereby yielding more complex information than is possible by chromogenic immunohistochemistry (IHC). However, many commercially-available multiplex IF kits are designed for use in conjunction with a multispectral imaging system, to which many research groups have limited access. Here we present two 5-colour IF panels designed for T cell characterisation in human colorectal tissue, which can be imaged using a non-spectral fluorescence slide scanner with standard band-pass filters. We describe the optimisation process and the key considerations in developing a multiplex fluorescence assay, and discuss some of the advantages and disadvantages of using multiplex IF with a non-spectral imaging system.

Objective: The objective of this study was to ascertain whether wearable technology coupled with action planning was effective in increasing physical activity (PA) in colorectal and endometrial cancer survivors at cardiovascular risk. Methods: Sixty-eight survivors who had cardiovascular risk factors and were insufficiently active were randomized to intervention and control arms. Intervention participants were given a wearable tracker for 12 weeks, two group sessions, and a support phone call. Participants in the control arm received print materials describing PA guidelines. Assessments at baseline and 12 weeks measured triaxial and uniaxial estimates of moderate-vigorous physical activity (MVPA), sedentary behaviour, blood pressure, and body mass index (BMI). Results: The intervention group significantly increased MVPA by 45 min/wk compared with a reduction of 21 min/wk in the control group. Group by time interactions were significant for minutes of MVPA (F 1,126 = 5.14, P = 0.025). For those with diastolic hypertension, there was a significant group by time interaction (F 1,66 = 4.89, P = 0.031) with a net reduction of 9.89 mm Hg in the intervention group. Conclusions: Significant improvements in MVPA were observed following the intervention. The results display promise for the use of pragmatic, low-intensity interventions using wearable technology. usc Refereed/Peer-reviewed

Immunoediting is defined as a process whereby tumour cells develop the capacity to escape immune cell recognition. Accumulating evidence suggests that cancer stem-like cells (CSCs) have an enhanced capacity to interact with the immune system. The expression of CSCs and immune cell-associated markers has been demonstrated to change with disease progression from premalignant lesions to invasive cancer. The present study investigated the expression of putative CSC and immune cell-associated markers in different stages of progression from dysplasia to invasive malignancy in rectal lesions. Immunohistochemistry was performed for the CSC markers Lgr5 and SOX2 and the immune-associated markers CD8, Foxp3 and PD-L1 in 79 cases of endoscopically-excised rectal lesions, ranging from low grade adenoma (LG) to invasive adenocarcinoma (AdCa). CD8 and Foxp3 expression significantly increased with advances in disease progression [AdCa vs. LG: Odds ratio (OR) 4.33; 95% confidence interval (CI), 1.16–16.3; P=0.03 and OR, 40.5; 95% CI, 6.57–249.6; P

To develop a risk-adjustment model for unplanned return to theatre (URTT) outcomes following colorectal surgeries in Australia and New Zealand hospitals and apply top-down and bottom-up statistical process control methods for fair comparison of hospitals and surgeons' URTT rates.We analysed URTT outcomes from hospitals contributing data to the Bi-National Colorectal Cancer Audit clinical registry between 2007 and 2016. Preoperative and intraoperative covariates were considered for risk adjustment. A risk-adjusted rate funnel plot was prepared for between-hospital comparisons and identification of outlying hospitals with unusually high rates of URTT. Cumulative observed-minus-expected charts with cumulative sum signals were then presented for surgeons within an outlying hospital.The study included 15 134 patients and 166 surgeons across 70 hospitals. The weighted average URTT rate was 5.2%. The risk-adjustment model identified 12 preoperative and intraoperative variables that significantly raise the risk of URTT: male sex, American Society of Anesthesiologists score, emergency admissions, conversion entry, left hemicolectomy, total colectomy, proctocolectomy, lower anterior resection, ultra-low anterior resection, abdominoperineal resection, organ resection and excess lymph nodes harvested. Right hemicolectomy significantly reduced risk of URTT. URTT rates were not found to significantly vary across seniority of operator; however, comparisons were limited by lack of data on junior operators. The funnel plot identified five hospitals as 'possible outliers' and hospital T was identified as a 'definite outlier'. The cumulative observed-minus-expected charts with cumulative sum signals showed that within hospital T, one surgeon among three had a particularly bad run of URTTs.Feedback from aggregated URTT outcomes using a risk-adjusted rate funnel plot is enhanced when follow-up examination of outlying hospitals is conducted with concurrent application of cumulative observed-minus-expected charts with cumulative sum signals.

Background Pathological complete response following neoadjuvant chemoradiotherapy (CRT) for locally advanced rectal cancer is associated with reduced local recurrence and improved long-term outcome. However, the prognostic value of a partial response, or of tumour regression in patients with metastatic disease, is less clear. Methods We present a single-centre cohort study of 205 patients with stage II–IV rectal cancer treated with surgery and neoadjuvant CRT between 2006 and 2013. Tumour regression was assessed using the Dworak system. Results The probability of 3-year recurrence-free survival (RFS) was 95% for Dworak grade 4, 82% for grade 3, 64% for grade 2 and 53% for grade 1 (P = 0.0005). In univariate regression analysis, Dworak grade was associated with RFS (hazard ratio (HR) 0.51, P < 0.0001; trend analysis) and cancer-specific survival (HR 0.52, P = 0.002). In multivariate analysis, Dworak grade remained an independent predictor of RFS (HR 0.62, P = 0.012), along with clinical metastases stage, resection margin status, the presence or absence of extramural venous invasion and type of surgical procedure. Conclusions Tumour regression grade after neoadjuvant CRT was an independent prognostic factor for RFS, highlighting the importance of the degree of local response to CRT.

Background: Foxp3+ regulatory T cells (Tregs) play a vital role in preventing autoimmunity, but also suppress antitumour immune responses. Tumour infiltration by Tregs has strong prognostic significance in colorectal cancer, and accumulating evidence suggests that chemotherapy and radiotherapy efficacy has an immune-mediated component. Whether Tregs play an inhibitory role in chemoradiotherapy (CRT) response in rectal cancer remains unknown. Methods: Foxp3+, CD3+, CD4+, CD8+ and IL-17+ cell density in post-CRT surgical samples from 128 patients with rectal cancer was assessed by immunohistochemistry. The relationship between T-cell subset densities and clinical outcome (tumour regression and survival) was evaluated. Results: Stromal Foxp3+ cell density was strongly associated with tumour regression grade (P=0.0006). A low stromal Foxp3+ cell density was observed in 84% of patients who had a pathologic complete response (pCR) compared with 41% of patients who did not (OR: 7.56, P=0.0005; OR: 5.27, P=0.006 after adjustment for presurgery clinical factors). Low stromal Foxp3+ cell density was also associated with improved recurrence-free survival (HR: 0.46, P=0.03), although not independent of tumour regression grade. Conclusions: Regulatory T cells in the tumour microenvironment may inhibit response to neoadjuvant CRT and may represent a therapeutic target in rectal cancer.

Background Outcomes of patients with stage I colorectal cancer submitted to surgery with curative intent have not been thoroughly explored in contemporary series. Methods All patients with colon or rectal adenocarcinoma who underwent resection from the St John of God Hospital (1996–2013) and BioGrid (1991–2013) databases were identified. Patients submitted to local excision, polypectomies or neoadjuvant treatment were excluded. Outcomes included recurrence (combined local and systemic), recurrence-free and overall survival, and survival after recurrence. Results A total of 1193 patients with stage I disease were included. Median age was 67 (interquartile range 59–75) and median follow-up was 3.2 years (interquartile range 1.4–5.8). Five-year recurrence rate was 7.1% (95% confidence interval (CI) 5.4–9.4%; 5.0% for colon and 11.1% for rectal cancer). Rectal location was an independent predictor of recurrence (hazard ratio (HR) 1.97, 95% CI 1.09–3.55; P = 0.024). Lymphovascular invasion was an independent predictor of recurrence only in patients with rectal cancer (HR 3.0, 95% CI 1.2–7.6; P = 0.018). Five-year recurrence-free survival was 83.2% (95% CI 80.3–85.4%). Age (HR 1.05, 95% CI 1.03–1.07; P

Objective To develop a peer-review model for assessment and quality improvement of cancer multidisciplinary teams (MDTs) and qualitatively assess its feasibility and acceptability in Australia. Design, setting and participants A peer-review methodology was developed, based on the United Kingdom's National Health Service peer-review model and a comprehensive literature review. This was pilot tested in three mature MDTs in different settings. Semi-structured interviews were conducted between December 2012 and July 2013 with all five peer reviewers and 17 MDT members. Thematic analysis was undertaken using a framework approach. Results Peer reviewers and MDT members found the process reasonable, constructive and useful; however, those involved in the preparation for the review found it time-consuming. Most MDT members considered the final report accurate and reflective of their service. Recommendations in the report were met with mixed reactions: several MDT members perceived some recommendations to be particularly relevant, while others viewed the same recommendations as impractical or of limited value. Many participants were unsure if recommendations would be fully implemented. The majority saw value in the process and expressed support for its implementation locally and nationally; however, feedback suggests the most appropriate format is yet to be established. Conclusions Peer review of cancer MDTs is feasible and acceptable. We describe valuable lessons learnt and recognise that further development of the proposed peer-review model and national benchmarking of MDTs against established outcome measures is required if this process is to be widely implemented.

Cancer stem-like cells are highly tumourigenic cells that can repopulate entire tumours after apparent successful treatment. Recent evidence suggests they interact with other cells in the tumour microenvironment, including immune cell subsets, to enhance their survival. The aim of this study was to determine whether the expression of immune cell markers in primary colon cancer impacts the prognostic significance of cancer stem-like cell marker expression. Immunohistochemistry was used to assess the expression of putative stem cell markers (ALDH1, CD44v6, CD133, Lgr5, SOX2) and immune cell related markers (CD3, CD8, FoxP3, PD-L1) in 104 patients with stage III colon cancer. Associations of marker expression with overall and cancer-specific survival were determined using Kaplan-Meier analysis. High SOX2 expression in the central tumour area was found to be an independent factor for poor cancer-specific survival [hazard ratio (HR) 6.19; 95% confidence interval (CI) 2.24-17.14; p=0.001]. When immune-related factors were taken into account, patients categorised as SOX2low/FoxP3high had good outcome (HR 0.164; 95%CI 0.066-0.406; p

Infusional 5-fluorouracil (5-FU) has been the standard radiation sensitizer in patients undergoing preoperative long-course chemoradiotherapy (CRT) for locally advanced rectal cancer in Australia. Capecitabine (Xeloda) is an oral 5-FU prodrug of comparable pharmacodynamic activity, currently preferred in place of 5-FU infusion, its established counterpart in neoadjuvant CRT for rectal cancer. The few studies quantifying pathological complete response (pCR) of Xeloda versus 5-FU have produced inconsistent results. We reviewed our own data to determine if the rates of pCR of oral capecitabine were non-inferior to intravenous 5-FU in patients undergoing neoadjuvant CRT for rectal cancer.A retrospective study was performed from a prospectively kept database. Four hundred and fifty-two patients received preoperative CRT from January 2006 to January 2016. Pelvic radiotherapy was delivered concurrently with capecitabine (n = 42) or infusional 5-FU (n = 341). The remaining received different chemotherapy regimens. Surgery was performed 6-12 weeks of CRT completion. Pathological responses were assessed using Dworak regression grading score (0-4). Clinical outcomes were evaluated in terms of local control and recurrence-free survival.The proportion of patients who had a tumour regression score of 4 (pCR) after CRT was 4/42 (9.5%) in the capecitabine group and 71/341 (20%) in the infusional 5-FU group (P = 0.082). pCR was an independent predictor for survival in this group of patients (hazard ratio: 0.002, P = 0.0001, 95% confidence interval: 0.0001-0.027).The use of capecitabine as neoadjuvant chemotherapy in patients with rectal cancer was associated with a reduced rate of pCR. However this difference did not achieve statistical significance.

The purpose of the current study was to explore colorectal cancer survivors’ information and support needs in relation to health concerns and health behaviour change. Face-to-face interviews were conducted with participants who had completed active treatment for cancer within the previous 2 years. Participants were colorectal cancer survivors (N = 24, men = 11, women = 13 M, age = 69.38 years, SD = 4.19) recruited from a hospital in Perth, Australia on the basis that they had existing morbidities that put them at increased risk of cardiovascular disease. Interview transcripts were analysed using thematic analysis. Results: Five main themes emerged: bowel changes; Lack of knowledge concerning healthy eating and physical activity; conflicting information; desire for support; and, need for simple messages and strategies to stay healthy. Where dietary recommendations were provided, these were to resolve bowel problems rather than to promote healthy eating. The provision of lifestyle advice from the oncologists is limited and patients’ lack knowledge of guidelines for diet and physical activity. Oncologists could provide patients with clear messages from the World Cancer Research Fund (2011); that is to increase physical activity and dietary fibre and reduce consumption of red meat, processed meat, alcohol and body fatness.

Background Urgent surgery for acute intestinal presentations is generally associated with worse outcomes than elective procedures. This study assessed the outcomes of patients undergoing urgent colorectal surgery. Methods Patients were identified from a prospective database. Surgery was classified as urgent when performed as soon as possible after resuscitation and usually within 24 h. Outcome measures included 30 days mortality, return to theatre, anastomotic leak and overall survival. Results Two hundred forty-nine patients were included in the analysis. Median age was 65 years (interquartile range 48–74). The most common presentations were obstruction (52.2%) and perforation (23.6%). Cancer was the disease process responsible for presentation in 47.8% of patients. Thirty-day mortality was 6.8%. Age (odds ratio 1.08 95% confidence interval (CI) 1.02–1.15; P = 0.01), American Society of Anesthesiologists 4 (odds ratio 7.14 95% CI 1.67–30.4; P = 0.008) and cancer (odds ratio 6.61 95% CI 1.53–28.45; P = 0.011) were independent predictors of 30 days mortality. Relaparotomy was required in six (2.4%) cases. A primary anastomosis was performed in 156 (62.6%) patients. Anastomotic leak occurred in four (2.5%) patients. In patients with cancer, overall 5-year survival was 28% (95% CI 19–37), corresponding to 54% (95% CI 35–70) for stages I and II, 50% (95% CI 24–71) for stage III and 6% (95% CI 1–17) for stage IV disease. Urgent surgery was independently associated with worse overall survival (hazard ratio 2.65; 95% CI 1.76–3.99; P < 0.001). Conclusion In patients undergoing an urgent resection within a colorectal unit, performing a primary anastomosis is feasible and safe in the majority, relaparotomies are required in a minority and urgent surgery is an important predictor of worse prognosis in those with colorectal cancer.

We showed earlier that routine screening for microsatellite instability (MSI) and loss of mismatch repair (MMR) protein expression in colorectal cancer (CRC) led to the identification of previously unrecognized cases of Lynch syndrome (LS). We report here the results of screening for LS in Western Australia (WA) during 1994-2012. Immunohistochemistry (IHC) for loss of MMR protein expression was performed in routine pathology laboratories, while MSI was detected in a reference molecular pathology laboratory. Information on germline mutations in MMR genes was obtained from the state's single familial cancer registry. Prior to the introduction of routine laboratory-based screening, an average of 2-3 cases of LS were diagnosed each year amongst WA CRC patients. Following the implementation of IHC and/or MSI screening for all younger (

Background Anastomotic leaks are a serious complication of bowel surgery. This study aimed to evaluate the rate and severity, and identify risk factors for leaks in patients undergoing bowel anastomoses. Methods Prospective evaluation was performed on patients undergoing bowel surgery within a colorectal surgical unit. Anastomotic leak was defined and graded according to severity. A nurse independently collected the information. Stepwise logistic regression analysis was performed. Results Two thousand three hundred and sixty-three patients underwent 2994 anastomoses. Their median age was 64 years. Seven per cent were emergency operations. Anastomotic leak occurred in 82 patients (2.7%). Sixty-three per cent of leaks were managed with drainage or re-operation. Ultra-low anterior resection (ULAR) was associated with the highest subgroup leak rate (7.3%). In multivariable analysis, independent predictors for a leak included ‘other’ pathologies (iatrogenic injury, ischaemia, radiation enteritis) (P = 0.016, odds ratio (OR): 6.3, 95% confidence interval (CI): 1.4–28.0), ULAR (P = 0.001, OR: 8.5, 95% CI: 2.3–31.2) and the surgeon (A: P < 0.001, OR: 3.4, 95% CI: 2.1–5.6). Conclusion Majority of predictors for anastomotic leak were fairly intuitive. Nonetheless, it was relevant to note the importance of the individual surgeon as an independent predictor for leaks.

Background Recent trials on rectal cancer have demonstrated significant improvements in local recurrence without improvements in overall survival. The aim of this paper was to define the influence of local recurrence on survival in a prospective series of patients who underwent R0 or R1 resections for rectal cancer. Methods Patients presenting with rectal cancer from 1996 to 2012 were prospectively audited. The study included patients who underwent an R0 or R1 resection. Local recurrence was defined as cancer regrowth detected in the pelvis regardless of whether or not new metastases were found elsewhere. Kaplan–Meier curves, smoothed hazard functions and Cox models using both time since diagnosis and age as the time scale were used to define the influence of local recurrence on overall survival. Results The study involved 483 patients, of mean age 66 years (standard deviation = 13) and a median follow-up of 5.2 years. The results at 5 years were overall survival 71% (95% confidence interval (CI) 66–75), local recurrence 7% (95% CI 5–10) and distant recurrence 18% (95% CI 14–22). Patients diagnosed with local recurrence died faster than patients diagnosed with either distant recurrence or no recurrence, and this was particularly obvious for younger patients (local hazard ratio (HR) 54, 95% CI 12–253 and distant HR19, 95% CI 4–80). Local recurrence that developed early following surgery also had worse survival outcomes. Conclusions Within this cohort of rectal cancer patients, the early development of local recurrence was the single most important indicator of a reduced survival, and carried a worse prognosis than the development of distant metastases alone.

Background: Aside from tumour stage and treatment, little is known about potential factors that may influence survival in colorectal cancer patients. The aim of this study was to investigate the associations between physical activity, obesity and smoking and disease-specific and overall mortality after a colorectal cancer diagnosis. Methods: A cohort of 879 colorectal cancer patients, diagnosed in Western Australia between 2005 and 2007, were followed up to 30 June 2012. Cox's regression models were used to estimate the hazard ratios (HR) for colorectal cancer-specific and overall mortality associated with self-reported pre-diagnosis physical activity, body mass index (BMI) and smoking.Results:Significantly lower overall and colorectal cancer-specific mortality was seen in females who reported any level of recent physical activity than in females reporting no activity. The colorectal cancer-specific mortality HR for increasing levels of physical activity in females were 0.34 (95% CI=0.15, 0.75), 0.37 (95% CI=0.17, 0.81) and 0.41 (95% CI=0.18, 0.90). Overweight and obese women had almost twice the risk of dying from any cause or colorectal cancer compared with women of normal weight. Females who were current smokers had worse overall and colorectal cancer-specific mortality than never smokers (overall HR=2.64, 95% CI=1.18, 5.93; colorectal cancer-specific HR=2.70, 95% CI=1.16, 6.29). No significant associations were found in males. Conclusion: Physical activity, BMI and smoking may influence survival after a diagnosis of colorectal cancer, with more pronounced results found for females than for males. Refereed/Peer-reviewed

Aim Human involvement in the collection and entering of information into a database leads to a degree of error. The aim of this study was to assess the concordance between two individuals blinded from each other who independently collected information on the same set of patients and entered it into a colorectal neoplasia database. Method A colorectal research nurse and a surgeon independently maintained an electronic database on all new patients admitted with colorectal neoplasia under the surgeon over a 5-year period. Twenty-three key endpoints were selected from the database in order to determine the agreement between the two observers. The κ statistic (for nominal and ordinal data) and the concordance correlation coefficient (for interval data) were used to determine the level of agreement between the two data sets. Results Both observers recorded 432 new referrals during this period. There was only complete concordance between the two databases with respect to the number of new patients and returns to theatre within 30 days. Nonetheless, there was almost perfect concordance between the two data sets for a majority of the endpoints. The most important areas of variance were in the length of stay (κ = 0.78), the American Society of Anesthesiology grade (κ = 0.41), emergency surgery (κ = 0.36), nodal staging (κ = 0.54) and time to recurrence (κ = 0.77). Conclusion This study highlights a number of important areas of data inaccuracy in a prospective colorectal database. The inaccuracies were due to observer bias, issues of data interpretation, or just difficulty in collecting the information accurately.

To assess pattern distribution and prognosis of the three anatomical entities of metastatic colorectal cancer, and influence of treatment of metastases on survival.Patients presenting with stage IV colorectal cancer (synchronous group), or who developed metastatic recurrence (metachronous group) after initial curative treatment between January 2005 and August 2015 were reviewed. Right sided (cecum to transverse colon), left sided (splenic flexure to sigmoid colon) and rectal cancers were identified. Distribution of metastases were noted as hepatic, lung or peritoneal.Of 374 patients, 276 were synchronous, 98 were metachronous. Metachronous group had a better 3-year survival (54%, 95% CI: 42-64 versus 33%, 95% CI: 27-39, log rank P = 0.0038). There were equal numbers of right (n = 119), left (n = 115) and rectal cancers (n = 140). Rectal cancers had a higher metastatic recurrence, yet demonstrated better 3-year survival (right colon 45%, 95% CI: 19-67, left colon 49%, 95% CI: 27-68, rectum 59%, 95% CI: 42-72, P = 0.39) due to higher proportions of metachronous patients undergoing treatment for metastases (40 versus 14%). Over half of all organ metastases spread to liver, with equal distribution from all three anatomical groups. Rectal cancers showed highest preponderance for lung metastases.Rectal cancers have a higher chance of recurring, with a higher metastatic rate to the lung, yet demonstrate better survival outcomes in metastatic colorectal cancer, reflecting the benefit of intervention for metastases.