Publications by authors named "Jane Young"

179 Publications

Are Surgeons Working Smarter or Harder? A Systematic Review Comparing the Physical and Mental Demands of Robotic and Laparoscopic or Open Surgery.

World J Surg 2021 Mar 26. Epub 2021 Mar 26.

Institute of Academic Surgery at Royal Prince Alfred Hospital (IAS RPA), Missenden Road, Camperdown, NSW, 2050, Australia.

Background: Minimally invasive surgical techniques such as robotic surgical platforms have provided favourable outcomes for patients, but the impact on surgeons is not well described. This systematic review aims to synthesize and evaluate the physical and mental impact of robotic surgery on surgeons compared to standard laparoscopic or open surgery.

Methods: A search strategy was developed to identify peer-reviewed English articles published from inception to end of December 2019 on the following databases: MEDLINE, PubMed, PsycINFO and Embase. The articles were assessed using a modified Newcastle-Ottawa tool.

Results: Of the 6563 papers identified, 30 studies were included in the qualitative synthesis of this review. Most of the included studies presented a high risk of bias. A total of 13 and 21 different physical and mental tools, respectively, were used to examine the impact on surgeons. The most common tool used to measure physical and mental demand were surface electromyography (N = 9) and the NASA Task Load Index (NASA-TLX; N = 8), respectively. Majority of studies showed mixed results for physical (N = 10) and mental impact (N = 7). This was followed by eight and six studies favouring RS over other surgical modalities for physical and mental impact, respectively.

Conclusion: Most studies showed mixed physical and mental outcomes between the three surgical modalities. There was a high risk of bias and methodological heterogeneity. Future studies need to correlate mental and physical stress with long-term impact on the surgeons.
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http://dx.doi.org/10.1007/s00268-021-06055-xDOI Listing
March 2021

Colorectal cancer survivorship: A systematic review and thematic synthesis of qualitative research.

Eur J Cancer Care (Engl) 2021 Mar 18:e13421. Epub 2021 Mar 18.

Centre for Medical Psychology and Evidence-Based Decision-Making (CeMPED), School of Psychology, Faculty of Science, The University of Sydney, Sydney, NSW, Australia.

Introduction: With rapid changes in treatments for colorectal cancer (CRC), qualitative research into CRC survivorship requires greater synthesis. This paper aims to fill this gap through a systematic review (PROSPERO CRD42019131576) and thematic synthesis of the qualitative literature on survivorship experiences across early-stage and advanced CRC survivors.

Methods: CINAHL, Embase, MEDLINE, PsycINFO and PubMed were searched for qualitative CRC survivorship papers. Titles, abstracts and full texts were screened. Included articles (n = 81) underwent data extraction, CASP qualitative bias ratings and thematic synthesis.

Results: Bowel dysfunction caused functional limitations and negative quality of life (QoL), while stomas posed threats to body image and confidence. Physical symptoms hindered return to work, increasing financial burdens. Survivors' unmet needs included information regarding symptom expectations and management, and ongoing support throughout recovery. Advanced and early-stage survivors shared similar experiences. Advanced survivors struggled with fear of cancer recurrence/progression and feelings of powerlessness. Functional limitations, financial impacts and sexuality in advanced survivors were underexplored areas.

Conclusion: CRC and its treatments impact survivors' QoL in all areas. A coordinated supportive care response is required to address survivors' unmet needs. Future qualitative studies should explore advanced CRC subpopulations, treatment-specific impacts on QoL and long-term (>5 years) impacts on CRC survivors.
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http://dx.doi.org/10.1111/ecc.13421DOI Listing
March 2021

Reply to Comment on: Complications and impact on quality of life of vertical rectus abdominis myocutaneous flaps for reconstruction in pelvic exenteration surgery.

Dis Colon Rectum 2021 Feb 18. Epub 2021 Feb 18.

Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia Department of Gastrointestinal Surgery, Ghent University Hospital, Ghent, Belgium (current affiliation) Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Sydney, New South Wales, Australia School of Public Health, The University of Sydney, Sydney, New South Wales, Australia. Institute of Academic Surgery at Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.

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http://dx.doi.org/10.1097/DCR.0000000000001992DOI Listing
February 2021

Feasibility and acceptability of a preoperative exercise program for patients undergoing major cancer surgery: results from a pilot randomized controlled trial.

Pilot Feasibility Stud 2021 Jan 13;7(1):27. Epub 2021 Jan 13.

Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Missenden Road, Camperdown, New South Wales, 2050, Australia.

Objective: To establish the feasibility and acceptability of a preoperative exercise program, and to obtain pilot data on the likely difference in key surgical outcomes to inform the sample size calculation for a full-scale trial.

Design: Pilot randomized controlled trial.

Setting: Royal Prince Alfred Hospital, Sydney, Australia.

Subjects: We included patients undergoing elective pelvic exenteration or cytoreductive surgery aged 18 to 80 years, who presented to the participating gastrointestinal surgeon at least 2 weeks prior to surgery. Patients presenting cognitive impairment, co-morbidity preventing participation in exercise, inadequate English language, currently participating in an exercise program or unable to attend the exercise program sessions were excluded.

Methods: Participants were randomized to a 2-6 weeks preoperative, face-to-face, individualised exercise program or to usual care. Feasibility was assessed with consent rates to the study, and for the intervention group, retention and adherence rates to the preoperative exercise program. Acceptability of the exercise program was assessed with a semi-structured questionnaire exploring the advice received and the amount, duration and intensity of the exercise program. In addition, postoperative complication rates (Clavien-Dindo), length of hospital stay and self-reported measures of health-related quality of life (SF-36v2) were collected at baseline, day before surgery and in-hospital up to discharge from hospital.

Results: Of 122 patients screened, 26 (21%) were eligible and 22 (85%) accepted to participate in the trial and were randomized to the intervention (11; 50%) or control group (11; 50%). The median age of the include participants was 63 years. Adherence to the preoperative exercise sessions was 92.7%, with all participants either satisfied (33%) or extremely satisfied (67%) with the overall design of the preoperative exercise program. No significant differences in outcomes were found between groups.

Conclusions: The results of our pilot trial demonstrate that a preoperative exercise program is feasible and acceptable to patients undergoing major abdominal cancer surgery. There is an urgent need for a definite trial investigating the effectiveness of a preoperative exercise program on postoperative outcomes in patients undergoing major abdominal cancer surgery. This could potentially reduce postoperative complication rates, length of hospital stay and subsequently overall health care costs.

Trial Registration: ACTRN12617001129370. Registered on August 1, 2017, https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=373396&showOriginal=true&isReview=true.
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http://dx.doi.org/10.1186/s40814-021-00765-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7805142PMC
January 2021

Complications and Impact on Quality of Life of Vertical Rectus Abdominis Myocutaneous Flaps for Reconstruction in Pelvic Exenteration Surgery.

Dis Colon Rectum 2020 09;63(9):1225-1233

Department of Colorectal Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.

Background: Pelvic exenteration for malignancy sometimes necessitates flap reconstruction.

Objective: This study's aim was to investigate flap-related morbidity.

Design: A prospective database was reviewed from 2003 to 2016. All medical charts, correspondence, and outpatient follow-up records up to May 2017 were reviewed.

Settings: This study was conducted at a tertiary referral unit.

Patients: Patients who underwent pelvic exenteration surgery were selected.

Interventions: Reconstruction was performed with a vertical rectus abdominis myocutaneous flap.

Main Outcome Measures: Primary outcome was flap-related complications (short or long term >3 months). Secondary outcomes were hospital stay, readmission, mortality, and quality of life (Short Form-36, Functional Assessment of Cancer Therapy for patients with colorectal cancer).

Results: Of 519 patients undergoing pelvic exenteration surgery, 87 (17%) underwent flap reconstruction. Median follow-up was 20 months (interquartile range, 8-39 months). Median age was 60 years (interquartile range, 51-66). Flap-related complications were found in 59 patients (68%), with minor recipient-site complications diagnosed in 33 patients (38%). In the short term, 15 patients experienced major recipient-site complications (17%), including flap separation (n = 7) and partial (n = 3) or complete necrosis (n = 4). Flap removal was required in 1 patient. Obesity was the single independent risk factor for short-term flap-related complications (p = 0.02). Hospital admission was significantly longer in patients with short-term major flap complications (median 65 days, p < 0.001) compared with patients without or with minor complications. There was no 90-day mortality. Patients who required flap reconstruction reported lower baseline quality-of-life scores than patients without flap reconstruction, but both recovered over time. In the long term, minor flap-related complications occurred in 12 patients, and 11 patients had major donor-site complications. Fourteen patients developed major recipient-site complications (16%), including sacral collections, enterocutaneous fistulas, perineal ulcer, or hernia.

Limitations: This was a retrospective analysis of prospectively collected data.

Conclusions: Vertical rectus abdominis myocutaneous flaps in pelvic exenteration surgery have a high incidence of morbidity that has significant impact on hospital stay and a temporary impact on quality of life. Flap reconstruction should be used selectively in pelvic exenteration surgery. See Video Abstract at http://links.lww.com/DCR/B274. COMPLICACIONES E IMPACTO EN LA CALIDAD DE VIDA DE LOS COLGAJOS MIOCUTÁNEOS DE MUSCULO RECTO DEL ABDOMEN EN CASOS DE RECONSTRUCCIÓN DE EXENTERACIÓN PÉLVICA: La exenteración pélvica (EP) para malignidad a veces requiere reconstrucción con colgajos musculares.El propósito del presente estudio fue investigar la morbilidad relacionada con los colagajos musculares.Revisión de una base de datos prospectiva de 2003-2016. Se evaluaron todas las historias clínicas, la correspondencia y los registros de seguimiento de pacientes ambulatorios hasta mayo de 2017.Unidad de referencia terciaria.Todos aquellas personas con cirugía de exenteración pélvica.Reconstrucción con colgajo miocutáneo de musculo recto vertical del abdomen.El resultado primario fueron las complicaciones relacionadas con el colgajo (a corto o largo plazo >3 meses). Los resultados secundarios fueron la estadía hospitalaria, la readmisión, la mortalidad y la calidad de vida (QOL; SF-36, FACT-C).De 519 pacientes sometidos a EP, 87 (17%) se sometieron a reconstrucción con colgajos miocutáneos. La mediana de seguimiento fue de 20 meses (RIC 8-39 meses). La mediana de edad fue de 60 años (IQR 51-66). Se encontraron complicaciones relacionadas con el colgajo en 59 pacientes (68%), con complicaciones menores en el sitio del receptor diagnosticadas en 33 pacientes (38%). A corto plazo, quince pacientes sufrieron complicaciones mayores en el sitio del receptor (17%), incluida la separación del colgajo (n = 7), necrosis parcial (n = 3) o necrosis completa (n = 4). Se requirió la extracción del colgajo en un paciente. La obesidad fue el único factor de riesgo independiente para complicaciones relacionadas con el colgajo a corto plazo (p = 0.02). El ingreso hospitalario fue significativamente mayor en pacientes con complicaciones de colgajos mayores a corto plazo (mediana 65 días p <0.001) en comparación con pacientes sin complicaciones menores o con complicaciones menores. No hubo mortalidad a los 90 días. Los pacientes que requirieron reconstrucción con colgajo informaron puntajes de calidad de vida basales más bajos que los pacientes sin reconstrucción con colgajo, pero ambos se recuperaron con el tiempo. A largo plazo, ocurrieron complicaciones menores relacionadas con el colgajo en 12 pacientes y 11 pacientes tuvieron complicaciones mayores en el sitio donante. Catorce pacientes desarrollaron complicaciones mayores en el sitio del receptor (16%), incluidas colecciones sacras, fístulas enterocutáneas, úlceras perineales o herniación.Análisis retrospectivo de datos recolectados prospectivamente.Los colgajos miocutáneos del musculo recto vertical del abdomen en casos de cirugía de exenteración pélvica tienen una alta incidencia de morbilidad conllevando a un impacto significativo en la estadía hospitalaria y un impacto temporal en la calidad de vida. Las reconstrucciones con colgajos deben aplicarse muy selectivamente en la cirugía de exenteración pélvica. Consulte Video Resumen en http://links.lww.com/DCR/B274.
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http://dx.doi.org/10.1097/DCR.0000000000001632DOI Listing
September 2020

Evidence on technology-driven preoperative exercise interventions: are we there yet?

Br J Anaesth 2020 11 15;125(5):646-649. Epub 2020 Jul 15.

Department of Allied Health, Peter MacCallum Cancer Centre, Melbourne, Australia; Melbourne School of Health Sciences, Faculty of Medicine Dentistry and Health Sciences, University of Melbourne, Melbourne, Australia.

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http://dx.doi.org/10.1016/j.bja.2020.06.050DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7363435PMC
November 2020

Risk factors and risk prediction models for colorectal cancer metastasis and recurrence: an umbrella review of systematic reviews and meta-analyses of observational studies.

BMC Med 2020 06 26;18(1):172. Epub 2020 Jun 26.

Centre for Global Health, Usher Institute, University of Edinburgh, Edinburgh, EH8 9AG, UK.

Background: There is a clear need for systematic appraisal of models/factors predicting colorectal cancer (CRC) metastasis and recurrence because clinical decisions about adjuvant treatment are taken on the basis of such variables.

Methods: We conducted an umbrella review of all systematic reviews of observational studies (with/without meta-analysis) that evaluated risk factors of CRC metastasis and recurrence. We also generated an updated synthesis of risk prediction models for CRC metastasis and recurrence. We cross-assessed individual risk factors and risk prediction models.

Results: Thirty-four risk factors for CRC metastasis and 17 for recurrence were investigated. Twelve of 34 and 4/17 risk factors with p < 0.05 were estimated to change the odds of the outcome at least 3-fold. Only one risk factor (vascular invasion for lymph node metastasis [LNM] in pT1 CRC) presented convincing evidence. We identified 24 CRC risk prediction models. Across 12 metastasis models, six out of 27 unique predictors were assessed in the umbrella review and four of them changed the odds of the outcome at least 3-fold. Across 12 recurrence models, five out of 25 unique predictors were assessed in the umbrella review and only one changed the odds of the outcome at least 3-fold.

Conclusions: This study provides an in-depth evaluation and cross-assessment of 51 risk factors and 24 prediction models. Our findings suggest that a minority of influential risk factors are employed in prediction models, which indicates the need for a more rigorous and systematic model construction process following evidence-based methods.
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http://dx.doi.org/10.1186/s12916-020-01618-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7318747PMC
June 2020

Quality of Life After Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy: Early Results from a Prospective Cohort Study of 115 Patients.

Ann Surg Oncol 2020 Oct 13;27(10):3986-3994. Epub 2020 Apr 13.

Peritoneal Malignancy Institute, Basingstoke, Basingstoke, UK.

Background: This study aimed to describe short- and medium-term longitudinal quality-of-life (QoL) outcomes after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC).

Methods: Consecutive patients undergoing CRS and HIPEC were recruited. The primary outcome was QoL, measured using the short-form 36 questionnaire and expressed as a physical component score (PCS) and a mental component score (MCS), with higher scores representing better QoL. Data were collected prospectively at baseline and before discharge, then 3, 6, and 12 months postoperatively. Trajectories of the PCS and MCS were described for the study period and grouped according to a peritoneal carcinomatosis index (PCI) (≤ 12 vs. ≥ 13) and a completeness of cytoreduction (CC) score (CC0 vs. CC1-CC3).

Results: Overall, 117 patients underwent CRS and HIPEC and 115 (98.3%) of the 117 patients participated in the study. The main primary pathology was colorectal in 52 (45%) of the 115 patients and appendiceal in 27 (23.5%) of the 115 patients. The median baseline PCS [48.16; interquartile range (IQR), 38.6-54.9] had decreased at pre-discharge (35.34; IQR, 28.7-41.8), then increased slightly at 3 months (42.54; IQR, 37.6-51.6), before returning to baseline within 6 months (48.35; IQR, 39.1-52.5) and remaining unchanged 12 months after surgery (48.55; IQR, 40.8-55.5). The MCS remained unchanged during the study period. The patients with a PCI of 13 or higher had worse PCS and MCS during the postoperative period than the patients with a PCI of 12 or lower.

Conclusions: The CRS and HIPEC procedures impaired PCS, with scores returning to baseline within 6 months after surgery, whereas MCS remained unchanged. The patients with a lower PCI had better postoperative QoL outcomes. For patients with peritoneal malignancy, CRS and HIPEC can be performed with acceptable short- to medium-term QoL outcomes.
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http://dx.doi.org/10.1245/s10434-020-08443-4DOI Listing
October 2020

What Constitutes a Clear Margin in Patients With Locally Recurrent Rectal Cancer Undergoing Pelvic Exenteration?

Ann Surg 2020 Feb 14. Epub 2020 Feb 14.

Surgical Outcomes Research Center (SOuRCe), Sydney, Australia.

Objectives: To determine what constitutes a clear resection margin (R0) in patients with LRRC.

Summary Of Background Data: R0 is the most important predictor of survival in patients with LRRC. However, it is not clear what constitutes an R0. A 1-2 mm margin is often used to define R0 but this is based on primary rectal cancer studies. The same definition of R0 is likely inappropriate considering the anatomy and etiology of local recurrences.

Methods: A prospective maintained database was reviewed. A R2 margin was defined as macroscopic residual disease. R1 was defined as a microscopically involved margin (0 mm margin) and R0 as at least a 0.1 mm margin. Associations between R status and local recurrence was explored using X test. Associations between margins and overall survival and local recurrence free survival were explored using Kaplan-Meier analysis.

Results: There were 210 patients eligible for inclusion for analysis. Of these, 165 (78.6%), 35 (16.7%), and 10 (4.8%) patients had R0, R1, and R2 margins, respectively. Overall survival was significantly different between patients with R0 versus R1 margins but wider resection margins do not confer a survival benefit [57 months (95% confidence interval 38.5-75.5) vs 33 months (95% confidence interval 20.3-45.7), P = 0.03]. Local recurrence free survival was significantly different between patients with R0 versus R1 margins (2- and 5-year local recurrence free survivals of 53.5% and 20.4% vs 25.9% and 14.8%, respectively, P = 0.001 for both). Margins >0.5 mm were not predictive of local recurrence free survival.

Conclusions: A microscopically clear resection margin is most important in predicting overall survival. Margins up to 0.5 mm offers a local recurrence benefit but does not confer survival benefit.
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http://dx.doi.org/10.1097/SLA.0000000000003834DOI Listing
February 2020

Influence of remoteness of residence on timeliness of diagnosis and treatment of oral cavity and oropharynx cancer: A retrospective cohort study.

J Med Imaging Radiat Oncol 2020 Apr 9;64(2):261-270. Epub 2020 Feb 9.

Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.

Introduction: Geographic disparities in head and neck cancer (HNC) outcomes in Australia may be mediated by timeliness of diagnosis and treatment. This retrospective cohort study examines geographic variations in survival and time intervals leading up to treatment for HNC at two tertiary referral centres in New South Wales.

Methods: Eligible patients were NSW residents aged ≥18 years, diagnosed with primary oropharynx or oral cavity squamous cell carcinoma (SCC) between 01 July 2008 and 30 June 2013, and treated with curative intent. Main outcomes were times from diagnosis to treatment and from surgery to post-operative radiotherapy and overall survival. Differences based on remoteness of residence (regional/remote or metropolitan) were assessed.

Results: A total of 224 patients were eligible. Median time from symptom onset to treatment was longer for regional/remote patients with oropharynx SCC (4.7 vs. 3.8 months, P = 0.044) and oral cavity SCC (6.4 vs. 3.3 months, P = 0.003). Median time from diagnosis to treatment was longer for regional/remote patients with oropharyngeal SCC (47 days vs. 36 days, P = 0.003). Time from surgery to adjuvant radiotherapy was longer among regional/remote patients with oral cavity SCC (66 vs. 42 days, P = 0.001). Overall survival did not differ based on remoteness.

Conclusion: Regional/remote HNC patients experienced longer times to diagnosis and treatment, and regardless of remoteness of residence, fewer than half of patients were treated within guideline recommended timeframes. Despite this non-adherence to guidelines, there were no differences in survival outcomes among this cohort. However, the impact of not meeting guidelines on patient outcomes other than survival warrants further investigation.
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http://dx.doi.org/10.1111/1754-9485.12990DOI Listing
April 2020

Urologists' referral and radiation oncologists' treatment patterns regarding high-risk prostate cancer patients receiving radiotherapy within 6 months after radical prostatectomy: A prospective cohort analysis.

J Med Imaging Radiat Oncol 2020 Feb 2;64(1):134-143. Epub 2019 Dec 2.

Cancer Research Division, Cancer Council NSW, Sydney, New South Wales, Australia.

Introduction: Previous studies have observed low rates of adjuvant radiotherapy after radical prostatectomy (RP) for high-risk prostate cancer patients. However, it is not clear the extent to which these low rates are driven by urologists' referral and radiation oncologists' treatment patterns.

Method: The Clinician-Led Improvement in Cancer Care (CLICC) implementation trial was conducted in nine public hospitals in New South Wales, Australia. Men who underwent RP for prostate cancer during 2013-2015 and had at least one high-risk pathological feature of extracapsular extension, seminal vesicle invasion and/or positive surgical margins were included in these analyses. Outcomes were as follows: (i) referral to a radiation oncologist within 4 months after RP ('referred'); (ii) commencement of radiotherapy within 6 months after RP among those who consulted a radiation oncologist ('radiotherapy after consultation').

Results: Three hundred and twenty-five (30%) of 1071 patients were 'referred', and 74 (61%) of 121 patients received 'radiotherapy after consultation'. Overall, the probability of receiving radiotherapy within 6 months after RP was 15%. The probability of being 'referred' increased according to higher 5-year risk of cancer-recurrence (P < 0.001).

Conclusion: Only 30% of patients with high-risk features are referred to a radiation oncologist with the likelihood of referral being influenced by the perceived risk of cancer-recurrence as well as the urologist's institutional/personal preference. When patients are seen by a radiation oncologist, 61% receive radiotherapy within 6 months after RP with the likelihood of receiving radiotherapy not being heavily influenced by increasing risk of recurrence. This suggests many suitable patients would receive radiotherapy if referred and seen by a radiation oncologist.
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http://dx.doi.org/10.1111/1754-9485.12979DOI Listing
February 2020

Re: Pre-treatment wait time for head and neck cancer patients in Western Australia: description of a new metric and examination of predictive factors.

ANZ J Surg 2019 11;89(11):1525-1526

Faculty of Medicine and Health, The University of Sydney, Sydney, New South Wales, Australia.

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http://dx.doi.org/10.1111/ans.15481DOI Listing
November 2019

Cross-Cultural Adaptation And Pilot Testing Of The Cancer Care Coordination Questionnaire For Patients (CCCQ-P) In Chinese And Arabic Languages.

Patient Prefer Adherence 2019 23;13:1791-1797. Epub 2019 Oct 23.

Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Camperdown, NSW, Australia.

Background: The Cancer Care Coordination Questionnaire for Patients (CCCQ-P) has been designed to measure patients' experience of this crucial aspect of their cancer care. Migrants are at particular risk of receiving poorly coordinated cancer care due to challenges in communication as well as unfamiliarity with the health system and roles of health professionals. The aim of this study was to cross-culturally adapt and pilot test the CCCQ-P in Chinese and Arabic languages.

Methods: This study followed an established five-stage process for cross-cultural adaptation of self-report measures. The CCCQ-P was forward and back-translated into Arabic, Simplified Chinese, and Traditional Chinese languages by two independent translators. An expert committee review panel appraised the translations, resulting in a pre-final version in the target languages. Face validity, content validity, and consistency of the translated CCCQ-P were then assessed in a sample of bilingual former cancer patients and health professionals. In addition, structured interviews were conducted to explore the meaning of each question and responses to participants.

Results: Thirteen health professionals (7 Chinese, 6 Arabic) and 19 former cancer patients (11 Chinese, 8 Arabic) participated in the face validation. Across both language groups, participants agreed that the cross-culturally adapted and translated versions had clear instructions and response options that were appropriate and understandable. All items were considered important and significant to the tool and so no item was removed. Complex medical words caused some differences in preferred terminology in Arabic and Chinese; however, participants agreed that the meaning of the questions and response options was not lost.

Conclusion: The Arabic, Simplified Chinese, and Traditional Chinese cross-culturally adapted and piloted versions of the CCCQ-P are useful tools to measure patients' experience of cancer care coordination. Further validation and psychometric testing of the instrument are warranted.
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http://dx.doi.org/10.2147/PPA.S221039DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6815751PMC
October 2019

Research as the gatekeeper: introduction ofrobotic-assisted surgery into the public sector.

Aust Health Rev 2019 Jan;43(6):676-681

RPA Institute of Academic Surgery (IAS), Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW 2050, Australia. Email: and University of Sydney, Sydney, NSW 2000, Australia. Email: and The Baird Institute, Sydney, NSW 2050, Australia. Email:

Objective Within Australia, robotic-assisted surgery (RAS) has largely been undertaken within the private sector, and predominately based within urology. This is rapidly developing, with RAS becoming increasingly prevalent across surgical specialties and within public hospitals. At this point in time there is a need to consider how this generation of the technology can be appropriately and safely introduced into the public health system given its prohibitive costs and lack of high-level long-term evidence. Methods This paper describes a unique approach used to govern the establishment of a new RAS program within a large public tertiary referral hospital in Australia. This included the creation of a comprehensive governance framework that covered research, training and operational components, with research being the ultimate gatekeeper to accessing the technology. Results Taking this novel approach, both benefits and challenges were encountered. Although initially there was a trade-off of activity to enable time for the research program to be developed, it was found the model strengthened patient safety in introducing the technology, fostered a breadth of surgical speciality involvement, ensured uniformity of data collection and, in the longer term, will enable a significant contribution to be made to the evidence regarding the appropriateness of RAS being used across several surgical specialties. Conclusions There is potential for this comprehensive governance framework to be transferred to other public hospitals commencing or with existing RAS programs and to be applied to the introduction of other new and expensive surgical technology. What is known about the topic? RAS is rapidly evolving and becoming increasingly prevalent across surgical specialities in major public hospitals. Consequently, it is important that this new technology is safely and appropriately implemented into the public health system. What does this paper add? This article describes the benefits and implementation challenges of a novel RAS approach, including a comprehensive governance framework that covered research, training and operational components, with research being the ultimate gatekeeper to accessing the technology. What are the implications for practitioners? This comprehensive governance framework can be transferred to other public hospitals introducing, or already using, new and expensive surgical technology.
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http://dx.doi.org/10.1071/AH19045DOI Listing
January 2019

Preliminary evidence for physical activity following pelvic exenteration: a pilot longitudinal cohort study.

BMC Cancer 2019 Jul 4;19(1):661. Epub 2019 Jul 4.

Falls, Balance and Injury Research Centre, Neuroscience Research Australia, University of New South Wales, 139 Barker Street, Randwick, 2031, New South Wales, Australia.

Background: The physical activity (PA) level of patients undergoing major cancer surgery remains unclear. This pilot study aimed to: (i) Compare preoperative PA level between patients undergoing major cancer surgery and the general population; (ii) describe PA trajectories following major cancer surgery; (iii) Compare objective versus subjective PA measures in patients undergoing major cancer surgery; and (iv) Investigate the association between preoperative PA level and postoperative outcomes.

Methods: Patients undergoing pelvic exenteration between September/2016 and September/2017 were included and followed at preoperative, 6-weeks and 6-months postoperative. PA was measured using the International Physical Activity Questionnaire Short-Form and McRoberts activity monitor. Analyses were performed using SPSS.

Results: This pilot study included 16 patients. When compared to the general population, patients undergoing major cancer surgery presented a reduced preoperative PA level. PA levels decreased at 6 weeks but returned to preoperative levels at 6 months postoperative. Objective and subjective measures of PA were comparable, with some variables presenting strong correlations. A higher preoperative level PA was associated with an absence of postoperative complications and better quality of life outcomes.

Conclusions: Patients undergoing major cancer surgery demonstrated lower PA levels when compared to the general population. PA trajectories decreased at 6 weeks postoperative, returning to preoperative levels within 6-months. In this cohort, it seems that higher preoperative PA level may improve postoperative surgical outcomes; however, this preliminary evidence should be confirmed in a larger cohort.
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http://dx.doi.org/10.1186/s12885-019-5860-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6610976PMC
July 2019

The burden of cancer on primary and secondary health care services before and after cancer diagnosis in New South Wales, Australia.

BMC Health Serv Res 2019 Jun 27;19(1):431. Epub 2019 Jun 27.

Cancer Institute NSW, Level 9, 8 Central Avenue, Australian Technology Park, Sydney, NSW, Australia.

Background: Primary and secondary healthcare service usage is assessed in the year before and following a cancer diagnosis, in cancer cases versus matched non-cancer controls in New South Wales (NSW), Australia over 2006-2012, for all invasive cancers collectively and for selected common sites: breast, prostate, colorectal and lung, and melanoma.

Methods: The 45 and Up cohort (n ≈267,000) was linked to NSW Cancer Register (NSWCR), Emergency Department Data Collection (EDDC) and Medical Benefits Schedule (MBS) data using probabilistic record linkage. First-ever malignant cancers diagnosed after enrolment in the 45 and Up study comprised the study cases. Where possible, five controls were randomly selected per case from the 45 and Up cohort, matched by sex and year of birth. Controls comprised those with no cancer recorded on the NSWCR. For each month in the year preceding and following the cancer diagnosis, general practitioner, specialist and specified hospital ED service use was compared between cases and controls using proportions, means, and odds ratios derived from conditional logistic regression.

Results: Compared to controls, cases of all cancers combined had a significantly higher likelihood of GP and specialist consultation in the year leading up to diagnosis. This was most pronounced in the 3-4 months leading up diagnosis for all cancers, similarly for lung cancer (GPs and specialists) and melanoma (GPs), and colorectal cancer (specialists). Likelihood of a GP consultation remained significantly higher in cases than controls in the 12 months following diagnosis. During most of the year preceding cancer diagnosis, the likelihood of specified ED presentations was also significantly higher in cases than controls for all cancers, and most pronounced in the 2-3 months before diagnosis. Excepting melanoma, the likelihood of specified ED presentations remained significantly elevated for most of the year following diagnosis for all cancers combined and for the selected cancers.

Conclusions: People with cancer experience a higher use of primary and secondary healthcare services in the year preceding and following diagnosis, with GPs continuing to play a significant role post diagnosis. The higher likelihood of pre-diagnosis GP consultations among cancer cases requires further investigation, including whether signals might be derived to alert GPs to possibilities for earlier cancer detection.
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http://dx.doi.org/10.1186/s12913-019-4280-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6598375PMC
June 2019

Addressing the ethical grey zone in surgery: a framework for identification and safe introduction of novel surgical techniques and procedures.

ANZ J Surg 2019 06 11;89(6):634-638. Epub 2019 Apr 11.

Institute of Academic Surgery, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.

While the introduction of new surgical techniques can radically improve patient care, they may equally expose patients to unforeseen harms associated with untested procedures. The enthusiastic uptake of laparoscopic cholecystectomy in the early 1990s saw a dramatic increase in the rate of common bile duct injuries, and was described by Alfred Cuschieri as 'the biggest unaudited free-for-all in the history of surgery' due to 'a lack of effective centralised control'. Whether a new surgical intervention is considered an acceptable 'minor' variation of an established procedure, or is sufficiently 'novel' to constitute experimentation on human subjects is often unclear. Furthermore, once a new technique is identified as experimental, there is no agreed protocol for safety evaluation in a first-in-human setting. In phase I (first-in-human) pharmacological trials only small, single arm cohorts of highly selected patients are enrolled in order to establish the safety profile of a new drug. This exposes only a small number of patients to the unknown or unforeseen risks that may be associated with a new agent, in a highly regulated and scientifically rigorous manner. There is no equivalent study design for the introduction of new and experimental surgical procedures. This article proposes a practical stepwise approach to the safe introduction of new surgical procedures that surgeons and surgical departments can adopt. It includes criteria for new surgical techniques which require formal prospective ethical evaluation, and a novel study design for conducting a safety evaluation at the 'first in human' stage.
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http://dx.doi.org/10.1111/ans.15104DOI Listing
June 2019

Is preoperative physical activity level of patients undergoing cancer surgery associated with postoperative outcomes? A systematic review and meta-analysis.

Eur J Surg Oncol 2019 04 21;45(4):510-518. Epub 2018 Oct 21.

Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia.

Background: There is uncertainty about the role of preoperative physical activity (PA) level and its influence on postoperative outcomes, especially for patients undergoing cancer surgery.

Aim: To investigate if the level of preoperative PA in patients undergoing cancer surgery is associated with postoperative complication rates, length of hospital stay (LOS) and quality of life (QOL).

Methods: An electronic search was performed from inception to 26th November 2017 in MEDLINE, Embase, AMED and CINAHL. Studies investigating the association between objective or subjective level of PA and postoperative complication rates, LOS and QOL were included. Risk of bias was assessed using the Quality in Prognosis Studies (QUIPS) tool. When possible, summary odds ratios (OR) and 95% confidence intervals (CI) were calculated using random-effect models.

Results: 13 studies (5523 unique patients) were included. Overall, most studies were rated as having low or moderate risk of bias. Higher preoperative level of PA was not significantly associated with absence of postoperative complications (OR = 2.60; 95%CI = 0.59 to 11.37) but was significantly associated with shorter LOS (OR = 3.66; 95%CI = 1.38 to 9.6) and postoperative QOL (OR = 1.29; 95%CI = 1.11 to 1.49).

Conclusions: The available literature suggests higher levels of preoperative PA in patients undergoing cancer surgery may be associated with better postoperative outcomes, particularly shorter LOS and better QOL. There is a need for high-quality studies investigating the association between preoperative PA and postoperative outcomes.

Systematic Review Registration: PROSPERO 2017 CRD42017082334. Available from:http://www.crd.york.ac.uk/PROSPERO/display_record.php?ID=CRD42017082334.
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http://dx.doi.org/10.1016/j.ejso.2018.10.063DOI Listing
April 2019

Health literacy and cancer care coordination in Chinese migrant patients and their carers: A cross-sectional survey.

Psychooncology 2019 05 18;28(5):1048-1055. Epub 2019 Mar 18.

Faculty of Science, School of Psychology, Psycho-oncology Co-operative Research Group, The University of Sydney, Sydney, NSW, Australia.

Objectives: This study aimed to describe the levels of health literacy and experience of care coordination among Chinese migrant patients with cancer and their carers in Australia, and to examine factors associated with these.

Methods: Patients' self-reported data were collected using the Health Literacy and Cancer Care Coordination questionnaires. We conducted multivariate linear regression analyses to investigate predictors of patients' health literacy and their care experience. Canonical correlation analysis was used to examine the relationship between patients' health literacy and their care experience.

Results: A total of 68 patients and eight carers participated in the survey. Patients and carers reported similar levels of health literacy, with the lowest scores being in the "Having sufficient information to manage health" and "Navigating the health system" subscales. Gender (P = 0.026, partial η  = 0.281) and educational attainment (P = 0.015, partial η  = 0.250) had significant and large effects on patients' health literacy, after controlling for each other. Educational attainment showed a significant and medium association with patients' experience of cancer care coordination (P = 0.041, partial η  = 0.101). A large and positive correlation was found between patients' health literacy and experience of cancer care coordination (canonical correlation = 0.81).

Conclusions: Our findings reveal the health literacy and care coordination needs of Chinese migrant patients with cancer in Australia, especially those with lower educational attainment. Future efforts are necessary to enhance Chinese migrants' health literacy and establish an accessible and easy-to-navigate care environment.
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http://dx.doi.org/10.1002/pon.5050DOI Listing
May 2019

Pathways to diagnosis of non-small cell lung cancer: a descriptive cohort study.

NPJ Prim Care Respir Med 2019 02 8;29(1). Epub 2019 Feb 8.

School of Public Health, University of Sydney, Sydney, NSW, Australia.

Little has been published on the diagnostic and referral pathway for lung cancer in Australia. This study set out to quantify general practitioner (GP) and lung specialist attendance and diagnostic imaging in the lead-up to a diagnosis of non-small cell lung cancer (NSCLC) and identify common pathways to diagnosis in New South Wales (NSW), Australia. We used linked health data for participants of the 45 and Up Study (a NSW population-based cohort study) diagnosed with NSCLC between 2006 and 2012. Our main outcome measures were GP and specialist attendances, X-rays and computed tomography (CT) scans of the chest and lung cancer-related hospital admissions. Among our study cohort (N = 894), 60% (n = 536) had ≥4 GP attendances in the 3 months prior to diagnosis of NSCLC, 56% (n = 505) had GP-ordered imaging (chest X-ray or CT scan), 39% (N = 349) attended a respiratory physician and 11% (N = 102) attended a cardiothoracic surgeon. The two most common pathways to diagnosis, accounting for one in three people, included GP and lung specialist (respiratory physician or cardiothoracic surgeon) involvement. Overall, 25% of people (n = 223) had an emergency hospital admission. For 14% of people (N = 129), an emergency hospital admission was the only event identified on the pathway to diagnosis. We found little effect of remoteness of residence on access to services. This study identified a substantial proportion of people with NSCLC being diagnosed in an emergency setting. Further research is needed to establish whether there were barriers to the timely diagnosis of these cases.
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http://dx.doi.org/10.1038/s41533-018-0113-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6368611PMC
February 2019

The Role of Antibiotics in Breast Pocket Irrigation and Implant Immersion: A Systematic Review.

Plast Reconstr Surg Glob Open 2018 Sep 14;6(9):e1868. Epub 2018 Sep 14.

Department of Breast Surgery, Chris O'Brien Lifehouse, Sydney, Australia.

Background: The usage of antibiotics and antiseptics to washout the breast pocket, or to soak the breast implant during surgery, has come under scrutiny in recent times. Guidelines from the Centers for Disease Control and Prevention give no recommendation for or against the usage of antibiotics in this regard. They do however offer a weak recommendation for washing tissues with iodophor. This systematic review aims to investigate the efficacy and impact of such topical antibiotic or antiseptic usage in reducing infection rates.

Methods: A systematic electronic search was performed on the PreMEDLINE, MEDLINE, EMBASE, and CENTRAL (Cochrane) databases from inception to April 2017. Reference search was performed manually through Scopus. Results of the searches were independently screened by 2 reviewers (A.F. and P.H.). Studies involving an implant or tissue expander, with appropriate controls were included. Meta-analyses were performed where possible and data summarized when not.

Results: Three retrospective cohort studies were found to fit the review requirements. No randomized control trials were found. These studies covered a period of 1996-2010 for a total of 3,768 women undergoing augmentative surgery. The usage of antibiotics in pocket washout or implant immersion resulted in lower infection rates (RR = 0.52; = 0.004; 95% CI = 0.34-0.81).

Conclusions: There is a clinical benefit in using antibiotics for breast pocket irrigation and implant immersion. However, the quality of the evidence obtained in this review is low; hence, we recommend a randomized control trial for a higher level of evidence on this important issue.
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http://dx.doi.org/10.1097/GOX.0000000000001868DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6191220PMC
September 2018

Self-selection in a population-based cohort study: impact on health service use and survival for bowel and lung cancer assessed using data linkage.

BMC Med Res Methodol 2018 08 8;18(1):84. Epub 2018 Aug 8.

School of Public Health, University of Sydney and Sydney Local Health District, Sydney, Australia.

Background: In contrast to aetiological associations, there is little empirical evidence for generalising health service use associations from cohort studies. We compared the health service use of cohort study participants diagnosed with bowel or lung cancer to the source population of people diagnosed with these cancers in New South Wales (NSW), Australia to assess the representativeness of health service use of the cohort study participants.

Methods: Population-based cancer registry data for NSW residents aged ≥45 years at diagnosis of bowel or lung cancer were linked to the 45 and Up Study, a NSW population-based cohort study (N~ 267,000). We measured hospitalisation, emergency department (ED) attendance and all-cause survival, and risk factor associations with these outcomes using administrative data for cohort study participants and the source population. We assessed bias in prevalence and risk factor associations using ratios of relative frequency (RRF) and relative odds ratios (ROR), respectively.

Results: People from major cities, non-English speaking countries and with comorbidites were under-represented among cohort study participants diagnosed with bowel (n = 1837) or lung (n = 969) cancer by 20-50%. Cohort study participants had similar hospitalisation and ED attendance compared with the source population. One-year survival after major surgical resection was similar, but cohort study participants had up to 25% higher post-diagnosis survival (lung cancer 3-year survival: RRF = 1.24, 95% confidence interval 1.12,1.37). Except for area-based socioeconomic position, risk factors associations with health service use measures and survival appeared relatively unbiased.

Conclusions: Absolute measures of health service use and risk factor associations in a non-representative sample showed little evidence of bias. Non-comparability of risk factor measures of cohort study participants and non-participants, such as area-based socioeconomic position, may bias estimates of risk factor associations. Primary and outpatient care outcomes may be more vulnerable to bias.
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http://dx.doi.org/10.1186/s12874-018-0537-3DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6083588PMC
August 2018

The LEAD study protocol: a mixed-method cohort study evaluating the lung cancer diagnostic and pre-treatment pathways of patients from Culturally and Linguistically Diverse (CALD) backgrounds compared to patients from Anglo-Australian backgrounds.

BMC Cancer 2018 Jul 21;18(1):754. Epub 2018 Jul 21.

Department of General Practice and Centre for Cancer Research, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Carlton, Australia.

Background: Lung cancer is the leading cause of cancer mortality worldwide. Early diagnosis and treatment is a key factor in reducing mortality and improving patient outcomes. To achieve this, it is important to understand the diagnostic pathways of cancer patients. Patients from Culturally and Linguistically Diverse (CALD) are a vulnerable group for lung cancer with higher mortality rates than Caucasian patients. The aim of this study is to explore differences in the lung cancer diagnostic pathways between CALD and Anglo-Australian patients and factors underlying these differences.

Methods: This is a prospective, observational cohort study using a mixed-method approach. Quantitative data regarding time intervals in the lung cancer diagnostic pathways will be gathered via patient surveys, General practitioner (GP) review of general practice records, and case-note analysis of hospital records. Qualitative data will be gathered via structured interviews with lung cancer patients, GPs, and hospital specialists. The study will be conducted in five study sites across three states in Australia. Anglo-Australian patients and patients from five CALD groups (i.e., Arabic, Chinese, Greek, Italian and Vietnamese communities) will mainly be identified through the list of new cases presented at lung multidisciplinary team meetings. For the quantitative component, it is anticipated that 724 patients (362 Anglo-Australian and 362 CALD patients) will be recruited to obtain a final sample of 290 (145 per group) assuming a 50% patient survey completion rate and a 80% GP record review completion rate. For the qualitative component, 60 interviews with lung cancer patients (10 Anglo-Australian and 10 patients per CALD group), 20 interviews with GPs, and 20 interviews with specialists will be conducted.

Discussion: This is the first Australian study to compare the time intervals along the lung cancer diagnostic pathway between CALD and Anglo-Australian patients. The study will also explore the underlying patient, healthcare provider, and health system factors that influence the time intervals in the two groups. This information will improve our understanding of the effect of ethnicity on health outcomes among lung cancer patients and will inform future interventions aimed at early diagnosis and treatment for lung cancer, particularly patients from CALD backgrounds.

Trial Registration: The project was retrospectively registered with Australian New Zealand Clinical Trials Registry (registration number: ACTRN12617000957392 , date registered: 4th July 2017).
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http://dx.doi.org/10.1186/s12885-018-4671-4DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6054738PMC
July 2018

Patients' experience of lung cancer care coordination: a quantitative exploration.

Support Care Cancer 2019 Feb 6;27(2):485-493. Epub 2018 Jul 6.

Sydney Catalyst Translational Cancer Research Centre, University of Sydney, Sydney, Australia.

Purpose: Improving the coordination of care for people with lung cancer is a health priority. This study aimed to tailor an existing care coordination survey for a lung cancer population, investigate coordination experiences for patients who had received hospital-based treatment and identify any factors that may be associated with poor care coordination.

Methods: We conducted a cross-sectional survey of lung patients within two tertiary hospitals in Sydney, Australia. The Cancer Care Coordination Questionnaire for Patients (CCCQ-P) is a psychometrically valid and reliable survey originally developed for colorectal cancer. We pilot tested a survey adaptation with lung cancer patients, support group members and medical specialists (n = 49). A revised survey was mailed to eligible patients via their medical specialist.

Results: Fifty-three of 118 eligible participants (45%) completed the CCCQ-P; most had early-stage disease and were about 70 years old. Overall, participants reported positive experiences of care coordination (mean total score 78.1), with high scores on communication and navigation subscales. The most problematic areas related to administrative aspects of care coordination and communication and information provision. Two patient groups (those residing in regional and rural areas, or no experience with the health system prior to diagnosis) reported significantly lower scores on the navigation subscale.

Conclusions: This study found that lung cancer patients' experience of care coordination was positive, but highlighted the need for strategies to assist patients living in rural areas, and those with no experience of the health care system. The CCCQ-P survey instrument can be used in future lung cancer studies.
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http://dx.doi.org/10.1007/s00520-018-4338-3DOI Listing
February 2019

Impact of serious mental illness on surgical patient outcomes.

ANZ J Surg 2018 May 14. Epub 2018 May 14.

RPA Institute of Academic Surgery, Royal Prince Alfred Hospital and The University of Sydney, Sydney, New South Wales, Australia.

Background: People with comorbid mental illness have poorer health status and disparate access to healthcare. Several studies internationally have reported mixed findings regarding the association between mental illness and surgical patient outcomes. This study examines the surgical outcomes in people with decompensated serious mental illness (SMI) within the setting of the Australian universal healthcare system.

Methods: Retrospective cohort study involving elective overnight surgical patients aged 18 years and above who attended a large public tertiary referral hospital in Sydney, Australia, between 2010 and 2014. Patients were identified using ICD-10-AM diagnosis codes. Outcomes measure including in-hospital mortality, post-operative complications, morbidity, admission and time in intensive care, length and cost of hospitalization, discharge destination and 28-day re-admission rates were examined.

Results: Of 23 343 surgical patient admissions, 451 (2%) patients had decompensated comorbid SMI with a subset of 47 (0.2%) having a specific psychotic illness. Patients with SMI comorbidity had significantly higher in-hospital mortality (2% versus 0%), post-operative complications (22% versus 8%), total comorbidity (7.6 versus 3.4 secondary codes), admissions (29% versus 9%) and time in intensive care (34.6 h versus 5.0 h), stay in hospital (12.2 days versus 4.6 days), admission costs ($24 162 versus $12 336), re-admission within 28 days (14% versus 10%) and discharges to another facility (11% versus 3%).

Conclusion: Patients with comorbid SMI had significantly worse surgical outcomes and incur much higher costs compared with the general surgical population. These results strongly highlight that specific perioperative interventions are needed to proactively improve the identification, management and outcomes for these disadvantaged patients.
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http://dx.doi.org/10.1111/ans.14508DOI Listing
May 2018

Effect of timing on baseline quality of life scores among surgical cancer patients.

BMC Res Notes 2018 Apr 2;11(1):210. Epub 2018 Apr 2.

Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), PO Box M157, Missenden Road, Sydney, NSW, 2050, Australia.

Objectives: To investigate differences between quality of life (QoL) scores obtained preoperatively or recalled in the early postoperative period amongst patients undergoing major cancer surgery.

Results: Of the 283 patients included, 133 completed their baseline QoL questionnaire preoperatively and 150 postoperatively. Patient groups were broadly comparable in terms of age however the preoperative group had a lower proportion of patients from non-English speaking backgrounds. There were important and statistically significant differences between mean scores for physical health (overall physical health, physical functioning and role physical domains) and mental health (overall mental health and mental health domains) between pre- and postoperative groups. There were no differences for other domain-specific scores (bodily pain, general health, vitality, social functioning and role emotional).
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http://dx.doi.org/10.1186/s13104-018-3312-yDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5879604PMC
April 2018

Patterns of follow up and survivorship care for people with colorectal cancer in new South Wales, Australia: a population-based survey.

BMC Cancer 2018 03 27;18(1):339. Epub 2018 Mar 27.

Surgical Outcomes Research Centre (SOuRCe), Sydney Local Health District and University of Sydney, Sydney, NSW, Australia.

Background: The incidence and survival rates for colorectal cancer in Australia are among the highest in the world. With population growth and ageing there are increasing numbers of colorectal cancer survivors in the community, yet little is known of their ongoing follow up and survivorship care experiences. This study investigated patterns and predictors of follow up and survivorship care received and recommended for adults with colorectal cancer in New South Wales (NSW), Australia.

Methods: Cross-sectional analysis within the NSW Bowel Cancer Care Survey, a population-based cohort of adults diagnosed with colorectal cancer between April 2012 and May 2013 in NSW. One year after diagnosis, participants completed a study specific questionnaire about their follow up and survivorship care experience and plans. Logistic regression was used to identify independent predictors of guideline-recommended care.

Results: Of 1007 eligible people, 560 (56%) participated in the NSW Bowel Cancer Care Survey with 483 (86% of study participants, 48% of invited sample) completing the survivorship survey. Among these 483 participants, only 110 (23%, 95% Confidence Interval CI 19-27%) had received a written follow up plan, with this more common among migrants, non-urban dwellers and those with little experience of the health system. Of 379 (78%) people treated with curative intent, most were receiving ongoing colorectal cancer follow up from multiple providers with 28% (23-32%) attending three or more different doctors. However, less than half had received guideline-recommended follow-up colonoscopy (46%, CI 41-51%) or carcino-embryonic antigen assay (35%, CI 30-40%). Socio-economic advantage was associated with receipt of guideline-recommended care. While participants reported high interest in improving general health and lifestyle since their cancer diagnosis, few had received advice about screening for other cancers (24%, CI 19-28%) or assistance with lifestyle modification (30%, CI 26-34%). Less than half (47%, CI 43-52%) had discussed their family's risk of cancer with a doctor since their diagnosis.

Conclusions: Survivorship care was highly variable, with evident socioeconomic disparities and missed opportunities for health promotion.
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http://dx.doi.org/10.1186/s12885-018-4297-6DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5869767PMC
March 2018

A multidisciplinary team-oriented intervention to increase guideline recommended care for high-risk prostate cancer: A stepped-wedge cluster randomised implementation trial.

Implement Sci 2018 03 12;13(1):43. Epub 2018 Mar 12.

Sax Institute, Haymarket, Australia.

Background: This study assessed whether a theoretically conceptualised tailored intervention centred on multidisciplinary teams (MDTs) increased clinician referral behaviours in line with clinical practice guideline recommendations.

Methods: Nine hospital Sites in New South Wales (NSW), Australia with a urological MDT and involvement in a state-wide urological clinical network participated in this pragmatic stepped wedge, cluster randomised implementation trial. Intervention strategies included flagging of high-risk patients by pathologists, clinical leadership, education, and audit and feedback of individuals' and study Sites' practices. The primary outcome was the proportion of patients referred to radiation oncology within 4 months after prostatectomy. Secondary outcomes were proportion of patients discussed at a MDT meeting within 4 months after surgery; proportion of patients who consulted a radiation oncologist within 6 months; and the proportion who commenced radiotherapy within 6 months. Urologists' attitudes towards adjuvant radiotherapy were surveyed pre- and post-intervention. A process evaluation measured intervention fidelity, response to intervention components and contextual factors that impacted on implementation and sustainability.

Results: Records for 1071 high-risk post-RP patients operated on by 37 urologists were reviewed: 505 control-phase; and 407 intervention-phase. The proportion of patients discussed at a MDT meeting increased from 17% in the control-phase to 59% in the intervention-phase (adjusted RR = 4.32; 95% CI [2.40 to 7.75]; p < 0·001). After adjustment, there was no significant difference in referral to radiation oncology (intervention 32% vs control 30%; adjusted RR = 1.06; 95% CI [0.74 to 1.51]; p = 0.879). Sites with the largest relative increases in the percentage of patients discussed also tended to have greater increases in referral (p = 0·001). In the intervention phase, urologists failed to provide referrals to more than half of patients whom the MDT had recommended for referral (78 of 140; 56%).

Conclusions: The intervention resulted in significantly more patients being discussed by a MDT. However, the recommendations from MDTs were not uniformly recorded or followed. Although practice varied markedly between MDTs, the intervention did not result in a significant overall change in referral rates, probably reflecting a lack of change in urologists' attitudes. Our results suggest that interventions focused on structures and processes that enable health system-level change, rather than those focused on individual-level change, are likely to have the greatest effect.

Trial Registration: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12611001251910 ). Registered 6 December 2011.
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http://dx.doi.org/10.1186/s13012-018-0733-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5848547PMC
March 2018

Feasibility and acceptability of PrE-operative Physical Activity to improve patient outcomes After major cancer surgery: study protocol for a pilot randomised controlled trial (PEPA Trial).

Trials 2018 Feb 17;19(1):112. Epub 2018 Feb 17.

Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital, Building 89, Level 9, Missenden Road, Camperdown, Sydney, NSW, 2050, Australia.

Background: There is a need for evidence of the effectiveness of pre-operative exercise for patients undergoing major cancer surgery; however, recruitment to such trials can be challenging. The PrE-operative Physical Activity (PEPA) Trial will establish the feasibility and acceptability of a pre-operative exercise programme aimed to improve patient outcomes after cytoreductive surgery and pelvic exenteration. The secondary aim is to obtain pilot data on the likely difference in key outcomes (post-operative complications, length of hospital stay, post-operative functional capacity and quality of life) to inform the sample size calculation for the substantive randomised clinical trial.

Methods/design: Twenty patients undergoing cytoreductive surgery and pelvic exenteration at the Royal Prince Alfred Hospital, Sydney will be recruited and randomly allocated (1:1 ratio) to either 2 to 6 weeks' pre-operative exercise programme (intervention group) or usual care (control group). Those randomised to the intervention group will receive up to six individualised, 1-h physiotherapy sessions (including aerobic and endurance exercises, respiratory muscle exercises, stretching and flexibility exercises), home exercises (instruction and recommendations on how to progress the exercises at home) and encouragement to be more active by using an activity tracker to measure the number of steps walked daily. Patients allocated to the control group will not receive any specific advice about exercise training. Feasibility will be assessed with consent rates to the study, and for the intervention group, retention and adherence rates to the exercise programme. Acceptability of the exercise programme will be assessed with a semi-structured questionnaire. The following measures of the effectiveness of the intervention will be collected at baseline (2 to 6 weeks pre-operative), a week before surgery, during hospital stay and pre hospital discharge: post-operative complication rates (Clavien-Dindo), post-operative functional capacity (Six-minute Walk Test) and quality of life (SF-36v2®) and length of hospital stay. Functional status will be additionally measured using Cardiopulmonary Exercise Testing (CPET), at baseline and within a week before surgery.

Discussion: The PEPA Trial will provide important information about the feasibility and acceptability of a pre-operative exercise programme for patients undergoing major cancer surgery. Data from the PEPA Trial will be used to inform the design, methodology and to calculate sample size required for a larger, definitive trial.

Trial Registration: Australian New Zealand Clinical Trials Registry, ID: ACTRN12617001129370 . Registered on 1 August 2017.
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http://dx.doi.org/10.1186/s13063-018-2481-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5816517PMC
February 2018

Preoperative exercise halves the postoperative complication rate in patients with lung cancer: a systematic review of the effect of exercise on complications, length of stay and quality of life in patients with cancer.

Br J Sports Med 2018 Mar 1;52(5):344. Epub 2018 Feb 1.

Surgical Outcomes Research Centre (SOuRCe), Royal Prince Alfred Hospital (RPAH), Sydney, NSW, Australia.

Objective: To investigate the effectiveness of preoperative exercises interventions in patients undergoing oncological surgery, on postoperative complications, length of hospital stay and quality of life.

Design: Intervention systematic review with meta-analysis.

Data Sources: MEDLINE, Embase and PEDro.

Eligibility Criteria For Selecting Studies: Trials investigating the effectiveness of preoperative exercise for any oncological patient undergoing surgery were included. The outcomes of interest were postoperative complications, length of hospital stay and quality of life. Relative risks (RRs), mean differences (MDs) and 95% CI were calculated using random-effects models.

Results: Seventeen articles (reporting on 13 different trials) involving 806 individual participants and 6 tumour types were included. There was moderate-quality evidence that preoperative exercise significantly reduced postoperative complication rates (RR 0.52, 95% CI 0.36 to 0.74) and length of hospital stay (MD -2.86 days, 95% CI -5.40 to -0.33) in patients undergoing lung resection, compared with control. For patients with oesophageal cancer, preoperative exercise was not effective in reducing length of hospital stay (MD 2.00 days, 95% CI -2.35 to 6.35). Although only assessed in individual studies, preoperative exercise improved postoperative quality of life in patients with oral or prostate cancer. No effect was found in patients with colon and colorectal liver metastases.

Conclusions: Preoperative exercise was effective in reducing postoperative complications and length of hospital stay in patients with lung cancer. Whether preoperative exercise reduces complications, length of hospital stay and improves quality of life in other groups of patients undergoing oncological surgery is uncertain as the quality of evidence is low. PROSPEROREGISTRATION NUMBER.
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http://dx.doi.org/10.1136/bjsports-2017-098032DOI Listing
March 2018