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Purpose Despite the benefits of palliative care (PC) in pancreatic cancer, little is known about patients who access PC. This observational study examines the characteristics of patients with pancreatic cancer at their first episode of PC. Methods First-time, specialist PC episodes captured through the Palliative Care Outcomes Collaboration (PCOC), in Victoria, Australia between 2014 and 2020, for pancreatic cancer, were identified. Multivariable logistic regression analyses examined the impact of patient- and service-level characteristics on symptom burden (measured through patient-reported outcome measures and clinician-rated scores) at first PC episode. Results Of 2890 eligible episodes, 45% began when the patient was deteriorating and 32% ended in death. High fatigue and appetite-related distress were most common. Generally, increasing age, higher performance status and more recent year of diagnosis predicted lower symptom burden. No significant differences were noted between symptom burden of regional/remote versus major city dwellers; however, only 11% of episodes recorded the patient as a regional/remote resident. A greater proportion of first episodes for non-English-speaking patients began when the patient was unstable, deteriorating or terminal, ended in death and were more likely to be associated with high family/carer problems. Community PC setting predicted high symptom burden, with the exception of pain. Conclusion A large proportion of first-time specialist PC episodes in pancreatic cancer begin at a deteriorating phase and end in death, suggesting late access to PC. Timely referrals to community-based specialist PC, access in regional/remote areas, as well as development of culturally diverse support systems require further investigation.

Background Registry-derived stage (RD-Stage) provides a mechanism to capture cancer stage at diagnosis from routinely captured data available to population-based cancer registries (PBCRs). In 2021, a project was undertaken to develop business rules to capture RD-Stage for endometrial cancer, understand current capacity to capture this information at a national level, and assess how it compares with stage recorded in clinical notes at diagnosis by clinicians. Methodology Business rules for deriving RD-stage (Endometrial carcinoma) were developed using AJCC Cancer Staging Manual 8th edition and endorsed by a tumour-specific Expert Working group comprising cancer specialists responsible for delivering cancer care and PBCR epidemiologists and medical coders. Baseline completeness of data fields required to calculate RD-Stage, and an overall proportion of cases for whom an RD stage could be assigned was assessed across each Australian jurisdiction. A validation study was undertaken in one jurisdiction to compare RD-Stage (Endometrial cancer) calculated by the Victorian Cancer Registry (VCR) with clinical stage recorded in cases diagnosed in 2018-2020 in the National Gynae-Oncology Registry (NGOR). Results The level of completeness of data to enable RD-Stage (Endometrial carcinoma) to be calculated across jurisdictions ranged from 0 to 89%. Three jurisdictions captured degree of spread of cancer only (instead of TNM data) and therefore captured no data which would enable RD-Stage to be calculated. The RD-Stage (Endometrial carcinoma) validation study found that RD-Stage could not be derived for 64/485 (13%) cases in the VCR and was not captured for 44/485 (9%) cases in NGOR. There was concordance at stage level (I, II, III, IV) in 393/410 (96%) of cases (95.8%, Kendall’s coefficient=0.95). Conclusion A lack of consistency in data captured by, and data sources reporting to, PBCRs meant that it was not possible to provide an accurate national baseline of endometrial carcinoma stage at diagnosis. In a sample of Victorian cases, there was very good concordance between RD-Stage (Endometrial carcinoma) and that recorded by clinicians in medical records and captured by NGOR. However, for 10% of cases RD-Stage could not be calculated because data was not available. RD-Stage provides a useful tool to be used for population epidemiological purposes.

BACKGROUND Leukaemias comprise a heterogenous group of haematological malignancies. In CONCORD-3, we analysed data for children (aged 0-14 years) and adults (aged 15-99 years) diagnosed with a haematological malignancy during 2000-14 in 61 countries. Here, we aimed to examine worldwide trends in survival from leukaemia, by age and morphology, in young patients (aged 0-24 years). METHODS We analysed data from 258 population-based cancer registries in 61 countries participating in CONCORD-3 that submitted data on patients diagnosed with leukaemia. We grouped patients by age as children (0-14 years), adolescents (15-19 years), and young adults (20-24 years). We categorised leukaemia subtypes according to the International Classification of Childhood Cancer (ICCC-3), updated with International Classification of Diseases for Oncology, third edition (ICD-O-3) codes. We estimated 5-year net survival by age and morphology, with 95% CIs, using the non-parametric Pohar-Perme estimator. To control for background mortality, we used life tables by country or region, single year of age, single calendar year and sex, and, where possible, by race or ethnicity. All-age survival estimates were standardised to the marginal distribution of young people with leukaemia included in the analysis. FINDINGS 164 563 young people were included in this analysis: 121 328 (73·7%) children, 22 963 (14·0%) adolescents, and 20 272 (12·3%) young adults. In 2010-14, the most common subtypes were lymphoid leukaemia (28 205 [68·2%] patients) and acute myeloid leukaemia (7863 [19·0%] patients). Age-standardised 5-year net survival in children, adolescents, and young adults for all leukaemias combined during 2010-14 varied widely, ranging from 46% in Mexico to more than 85% in Canada, Cyprus, Belgium, Denmark, Finland, and Australia. Individuals with lymphoid leukaemia had better age-standardised survival (from 43% in Ecuador to ≥80% in parts of Europe, North America, Oceania, and Asia) than those with acute myeloid leukaemia (from 32% in Peru to ≥70% in most high-income countries in Europe, North America, and Oceania). Throughout 2000-14, survival from all leukaemias combined remained consistently higher for children than adolescents and young adults, and minimal improvement was seen for adolescents and young adults in most countries. INTERPRETATION This study offers the first worldwide picture of population-based survival from leukaemia in children, adolescents, and young adults. Adolescents and young adults diagnosed with leukaemia continue to have lower survival than children. Trends in survival from leukaemia for adolescents and young adults are important indicators of the quality of cancer management in this age group. FUNDING Children with Cancer UK, the Institut National du Cancer, La Ligue Contre le Cancer, Centers for Disease Control and Prevention, Swiss Re, Swiss Cancer Research foundation, Swiss Cancer League, Rossy Family Foundation, US National Cancer Institute, and the American Cancer Society.

To compare treatments for localised prostate cancer for men diagnosed in private and public health services in Victoria.Retrospective analysis of Victorian Cancer Registry data linked to population-based administrative health datasets.29 325 Victorian men diagnosed with prostate cancer during 2011-2017.Proportions of men in private and public health services receiving radical prostatectomy (with or without curative radiation therapy) or curative external beam radiation therapy alone within 12 months of diagnosis.After adjusting for age, tumour classification and comorbidity, men diagnosed in private health services received radical treatment more frequently than men diagnosed in public health services (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.31-1.49). The proportion of private patients who underwent radical prostatectomy was larger than that for public patients (44% v 28%; OR, 2.28; 95% CI, 2.13-2.44) and the proportion of private patients who received curative external beam radiation therapy alone (excluding brachytherapy) was smaller (9% v 19%; OR, 0.45; 95% CI, 0.42-0.49). These differences were apparent for all International Society of Urological Pathology (ISUP) tumour grades. The magnitude of the difference for prostatectomy was greater for men aged 70 years or more; for radiation therapy alone, it was larger for those diagnosed before age 70. The differences between private and public services narrowed during 2011-2017 for men with ISUP grade 1 disease, but not ISUP grade 2-5 tumours.Prostate cancer treatment choices differ substantially between men diagnosed in private and public health services in Victoria. These differences are not explained by disease severity or comorbidity.

Background:\ud Greater understanding of international cancer survival differences is needed. We aimed to identify predictors and consequences of cancer diagnosis through emergency presentation in different international jurisdictions in six high-income countries.\ud \ud Methods:\ud Using a federated analysis model, in this cross-sectional population-based study, we analysed cancer registration and linked hospital admissions data from 14 jurisdictions in six countries (Australia, Canada, Denmark, New Zealand, Norway, and the UK), including patients with primary diagnosis of invasive oesophageal, stomach, colon, rectal, liver, pancreatic, lung, or ovarian cancer during study periods from Jan 1, 2012, to Dec 31, 2017. Data were collected on cancer site, age group, sex, year of diagnosis, and stage at diagnosis. Emergency presentation was defined as diagnosis of cancer within 30 days after an emergency hospital admission. Using logistic regression, we examined variables associated with emergency presentation and associations between emergency presentation and short-term mortality. We meta-analysed estimates across jurisdictions and explored jurisdiction-level associations between cancer survival and the percentage of patients diagnosed as emergencies.\ud \ud Findings:\ud In 857 068 patients across 14 jurisdictions, considering all of the eight cancer sites together, the percentage of diagnoses through emergency presentation ranged from 24·0% (9165 of 38 212 patients) to 42·5% (12 238 of 28 794 patients). There was consistently large variation in the percentage of emergency presentations by cancer site across jurisdictions. Pancreatic cancer diagnoses had the highest percentage of emergency presentations on average overall (46·1% [30 972 of 67 173 patients]), with the jurisdictional range being 34·1% (1083 of 3172 patients) to 60·4% (1317 of 2182 patients). Rectal cancer had the lowest percentage of emergency presentations on average overall (12·1% [10 051 of 83 325 patients]), with a jurisdictional range of 9·1% (403 of 4438 patients) to 19·8% (643 of 3247 patients). Across the jurisdictions, older age (ie, 75–84 years and 85 years or older, compared with younger patients) and advanced stage at diagnosis compared with non-advanced stage were consistently associated with increased emergency presentation risk, with the percentage of emergency presentations being highest in the oldest age group (85 years or older) for 110 (98%) of 112 jurisdiction-cancer site strata, and in the most advanced (distant spread) stage category for 98 (97%) of 101 jurisdiction-cancer site strata with available information. Across the jurisdictions, and despite heterogeneity in association size (I2=93%), emergency presenters consistently had substantially greater risk of 12-month mortality than non-emergency presenters (odds ratio >1·9 for 112 [100%] of 112 jurisdiction-cancer site strata, with the minimum lower bound of the related 95% CIs being 1·26). There were negative associations between jurisdiction-level percentage of emergency presentations and jurisdiction-level 1-year survival for colon, stomach, lung, liver, pancreatic, and ovarian cancer, with a 10% increase in percentage of emergency presentations in a jurisdiction being associated with a decrease in 1-year net survival of between 2·5% (95% CI 0·28–4·7) and 7·0% (1·2–13·0).\ud \ud Interpretation:\ud Internationally, notable proportions of patients with cancer are diagnosed through emergency presentation. Specific types of cancer, older age, and advanced stage at diagnosis are consistently associated with an increased risk of emergency presentation, which strongly predicts worse prognosis and probably contributes to international differences in cancer survival. Monitoring emergency presentations, and identifying and acting on contributing behavioural and health-care factors, is a global priority for cancer control.\ud \ud Funding:\ud Canadian Partnership Against Cancer; Cancer Council Victoria; Cancer Institute New South Wales; Cancer Research UK; Danish Cancer Society; National Cancer Registry Ireland; The Cancer Society of New Zealand; National Health Service England; Norwegian Cancer Society; Public Health Agency Northern Ireland, on behalf of the Northern Ireland Cancer Registry; the Scottish Government; Western Australia Department of Health; and Wales Cancer Network.

To evaluate the proportion of cancer patients who received radiation therapy (RT) within 12 months of cancer diagnosis (RTU12) and identify factors associated with RTU12.This is a population-based cohort of individuals with incident cancer, diagnosed between 2013 and 2017 in Victoria. Data linkages were performed between the Victorian Cancer Registry and Victorian Radiotherapy Minimum Dataset. The primary outcome was the proportion of patients who had RTU12. For the three most common cancers (i.e., prostate, breast and lung cancer), the time trend in RTU12 and factors associated with RTU12 were evaluated.The overall RTU12 in our study cohort was 26-20% radical RT and 6% palliative RT. Of the 21,735 men with prostate cancer, RTU12 was 17%, with no significant change over time (P-trend = 0.53). In multivariate analyses, increasing age and lower socioeconomic status were independently associated with higher RTU12 for prostate cancer. Of the 20,883 women with breast cancer, RTU12 was 64%, which increased from 62% in 2013 to 65% in 2017 (P-trend 0.05). In multivariate analyses, age, socioeconomic status and area of residency were independently associated with RTU12 for breast cancer. Of the 13,093 patients with lung cancer, RTU12 was 42%, with no significant change over time (P-trend = 0.16). In multivariate analyses, younger age, male and lower socioeconomic status were independently associated with higher RTU12.In this large population-based state-wide cohort of cancer patients, only 1 in 4 had RT within 12 months of diagnosis. There were marked sociodemographic disparities in RTU12 for prostate, breast and lung cancer patients.

Introduction: Pancreatic cancer (PC) has a dismal prognosis, with identified disparities in survival outcomes based on demographic characteristics. These disparities may be ameliorated by equitable access to treatments and health services. This systematic review identifies patient and service-level characteristics associated with PC health service utilisation (HSU). Methods: Medline, Embase, CINAHL, PsycINFO and Scopus were systematically searched between 1(st) January, 2010 and 17 May, 2021 for population-based, PC studies which conducted univariable and/or multivariable regression analyses to identify patient and/or service-level characteristics associated with use of a treatment or health service. Direction of effect sizes were reported in an aggregate manner. Results: Sixty-two eligible studies were identified. Most (48/62) explored the predictors of surgery (n=25) and chemotherapy (n=23), and in populations predominantly based in the United States of America (n=50). Decreased HSU was observed among people belonging to older age groups, non-Caucasian ethnicities, lower socioeconomic status (SES) and lower education status. Non-metropolitan location of residence predicted decreased use of certain treatments, and was associated with reduced hospitalisations. People with comorbidities were less likely to use treatments and services, including specialist consultations and palliative care but were more likely to be hospitalised. A more recent year of diagnosis/year of death was generally associated with increased HSU. Academically affiliated and high-volume centres predicted increased treatment use and hospital readmissions. Conclusion: Findings of this review may assist identification of vulnerable patient groups experiencing disparities in accessing and using treatments and therapies.

BACKGROUND Colorectal cancer is the third most commonly diagnosed malignancy in Australia. Up to a third of patients who have undergone surgery with curative intent for colorectal cancer will have a recurrence of disease leading to significant morbidity and mortality. Regional Australians have disproportionately worse outcomes. AIM To identify factors associated with recurrence in colorectal cancer patients treated at a regional Australian hospital. METHODS This study is a retrospective cohort analysis. Consecutive patients who have undergone curative resection at a regional public and private hospital by three surgeons from a single surgical practice for either rectal cancer or colon cancer were included. Prognostic indicators of recurrence were examined via both univariate and multivariate time-to-event analyses. RESULTS Three hundred nine patients were included with 43 recurrences. Thirty presented with distant metastases, seven presented with locoregional recurrence and six presented with locoregional as well as distant recurrence. In univariable analysis, higher rates of recurrence were associated with tumour type, higher AJCC summary stage, higher preoperative levels of CA19-9, perineural invasion, lymphovascular invasion

Background: Socio-economic inequalities in colon cancer survival exist in high-income countries, but the reasons are unclear. We assessed the mediating effects of stage at diagnosis, comorbidities, and treatment (surgery and intravenous chemotherapy) on survival from colon cancer. Methods: We identified 2,203 people aged 15 to 79 years with first primary colon cancer diagnosed in Victoria, Australia, between 2008 and 2011. Colon cancer cases were identified through the Victorian Cancer Registry (VCR), and clinical information was obtained from hospital records. Deaths till December 31, 2016 (n = 807), were identified from Victorian and national death registries. Socio-economic disadvantage was based on residential address at diagnosis. For stage III disease, we decomposed its total effect into direct and indirect effects using interventional mediation analysis. Results: Socio-economic inequalities in colon cancer survival were not explained by stage and were greater for men than women. For men with stage III disease, there were 161 [95% confidence interval (CI), 67–256] additional deaths per 1,000 cases in the 5 years following diagnosis for the most disadvantaged compared with the least disadvantaged. The indirect effects through comorbidities and intravenous chemotherapy explained 6 (95% CI, −10–21) and 15 (95% CI, −14–44) per 1,000 of these additional deaths, respectively. Surgery did not explain the observed gap in survival. Conclusions: Disadvantaged men have lower survival from stage III colon cancer that is only modestly explained by having comorbidities or not receiving chemotherapy after surgery. Impact: Future studies should investigate the potential mediating role of factors occurring beyond the first year following diagnosis, such as compliance with surveillance for recurrence and supportive care services.

Few large-scale studies have investigated sex differences in cancer survival and little is known about their temporal and age-related patterns. We used cancer registry data for first primary cancers diagnosed between 1982 and 2015 in Victoria, Australia. Cases were followed until the end of 2015 through linkage to death registries. Differences in survival were assessed for 25 cancers using the Pohar-Perme estimator of net survival and the excess mortality rate ratio (EMRR) adjusting for age and year of diagnosis. Five-year net survival for all cancers combined was lower for men (47.1%; 95% CI 46.9–47.4) than women (52.0%; 95% CI 51.7–52.3); EMRR 1.13 (95% CI 1.12–1.14; p

Background The Victorian Pancreas Cancer summit 2017 analysed state-wide data on management of Victorians with pancreas cancer between 2011 and 2015 to identify variations in care and outcomes. Pancreas cancer remains a formidable disease but systemic therapies are increasingly effective. Surgery remains essential but insufficient alone for cure. Understanding patterns of care and identifying variations in treatment is critical to improving outcomes. Methods This population-based study analysed data collected prospectively by Department of Health and Human services (Victorian state government). Data were extracted from Victorian Cancer Registry (covering all Victorian cancer diagnoses), Victorian Admitted-Episodes Dataset (all inpatient data), Victorian Radiotherapy Minimum Dataset and Victorian Death Index providing demographics, tumour and treatment characteristics, age-standardized incidence, overall and median survival. Results Of 3962 Victorian patients with any form of pancreatic malignancy, 82% were ductal adenocarcinoma (PDAC), of whom 67% had metastases at diagnosis. One-year overall survival for PDAC was 30% (60% non-metastatic, 15% if metastatic). Median survival with metastases increased from 2.7 to 3.9 months, and from 13.3 to 15.9 months for non-metastatic PDAC between 2011 and 2015. Thirty-one percent of non-metastatic patients underwent pancreatectomy. About 1.5% were treated with neoadjuvant chemotherapy/chemoradiation. Of patients undergoing intended curative resection, 77% proceeded to adjuvant therapy. Fifty-one percent of metastatic PDAC patients never received anti-tumour therapy. Conclusions Nearly one-fourth of surgically treated patients never received systemic therapy. More than two-thirds of non-metastatic patients never proceeded to surgery. Further consideration of neoadjuvant therapy should be given to borderline resectable patients. Most patients with PDAC still die soon after diagnosis, but median survival is increasing.

Objective: Length of hospital stay (LOS) is considered a vital component for successful colorectal surgery treatment. Evidence of an association between hospital surgery volume and LOS has been mixed. Data modelling techniques may give inconsistent results that adversely impact conclusions. This study applied techniques to overcome possible modelling drawbacks. Method: An additive quantile regression model formulated to isolate hospital contextual effects was applied to every colorectal surgery for cancer conducted in Victoria, Australia, between 2005 and 2015, involving 28,343 admissions in 90 Victorian hospitals. The model compared hospitals’ operational efficiencies regarding LOS. Results: Hospital LOS operational efficiencies for colorectal cancer surgery varied markedly between the 90 hospitals and were independent of volume. This result was adjusted for pertinent patient and hospital characteristics. Conclusion: No evidence was found that higher annual surgery volume was associated with lower LOS for patients undergoing colorectal cancer surgery. Our model showed strong evidence that differences in LOS efficiency between hospitals was driven by hospital contextual effects that were not predicted by provider volume. Further study is required to elucidate these inherent differences between hospitals. Implications for public health: Our model indicated improved efficiency would benefit the patient and medical system by lowering LOS and reducing expenditure by more than $3 million per year.

Objective To compare treatments for localised prostate cancer for men diagnosed in private and public health services in Victoria. Design Retrospective analysis of Victorian Cancer Registry data linked to population-based administrative health datasets. Setting, participants 29 325 Victorian men diagnosed with prostate cancer during 2011-2017. Main outcome measures Proportions of men in private and public health services receiving radical prostatectomy (with or without curative radiation therapy) or curative external beam radiation therapy alone within 12 months of diagnosis. Results After adjusting for age, tumour classification and comorbidity, men diagnosed in private health services received radical treatment more frequently than men diagnosed in public health services (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.31-1.49). The proportion of private patients who underwent radical prostatectomy was larger than that for public patients (44% v 28%; OR, 2.28; 95% CI, 2.13-2.44) and the proportion of private patients who received curative external beam radiation therapy alone (excluding brachytherapy) was smaller (9% v 19%; OR, 0.45; 95% CI, 0.42-0.49). These differences were apparent for all International Society of Urological Pathology (ISUP) tumour grades. The magnitude of the difference for prostatectomy was greater for men aged 70 years or more; for radiation therapy alone, it was larger for those diagnosed before age 70. The differences between private and public services narrowed during 2011-2017 for men with ISUP grade 1 disease, but not ISUP grade 2-5 tumours. Conclusion Prostate cancer treatment choices differ substantially between men diagnosed in private and public health services in Victoria. These differences are not explained by disease severity or comorbidity.

Background: While Australia ranks highly in terms of cancer survival internationally, disparities in outcomes exist within the nation. To address this issue, Optimal Care Pathways (OCPs) were developed as a standard of care. Key principles of care, timeframes, quality standards and support needs were described in a seven-step pathway for 18 cancers. This paper discusses the potential value of pathways for care delivery, contextualises Australia's pathway policy approach and describes implementation strategies and early evidence of OCP impact. Methods: A literature review assessed international definitions and evidence of the utility of clinical care pathways. OCP implementation and evaluation approaches are described and case studies presented to demonstrate policy impact. Results: Australia's OCPs extend the traditional definition of care pathways by incorporating core principles and addressing the entire pathway from prevention to survivorship and end of life. In 2014−15, tumour-specific OCPs were developed drawing on the best-available evidence and stakeholder collaboration. After government endorsement, implementation tools and strategies were developed, with tailored roll-out in each of Australia's six states and two territories. Evaluation of implementation projects shows improved knowledge, awareness, and use of OCPs as tools for monitoring and improving performance. Population-based data confirm a positive relationship between care aligned with OCPs and cancer survival. Conclusion: OCPs are clinician- and consumer-built policy levers, supported by high-level government endorsement, to improve cancer outcomes for all Australians. Early findings suggest positive impacts on care quality and cancer survival. Low and high resource countries may consider similar pathway policies to improve cancer outcomes.

Background - Causes of variations in outcomes from cancer care in developed countries are often unclear and multifactorial. The pathways by which a patient travels to access health care services and the impact of health as a system on outcomes is not well understood. In this study, we sought to understand what factors within health system pathways influenced outcomes by measuring clinical care compliance with an evidenced-based pathway - the Optimal Care Pathway (OCP). The OCP is a framework outlining standards of care from pre-diagnosis to end-of-life care. Methods - Colon patients diagnosed from 2008-14 were identified from the Australian State of Victoria Cancer Registry (VCR) and cases linked with State and Federal health datasets. The impact of pathway deviations on outcomes was estimated. Findings- Compliance with the prevention phase of the OCP occurred for 88% of 13,539 individuals and was associated with lower disease stage at diagnosis (OR = 0.33 [95% CI = 0.24 - 0.42]), improved three year survival (69.2% vs 62.2%; p

Reproduction is energetically expensive and to obtain sufficient energy, animals can either alter their metabolic system over time to increase energy intake (increased-intake hypothesis), or reallocate energy from maintenance processes (compensation hypothesis). The first hypothesis predicts a positive relationship between basal metabolic rate (BMR) and energy expenditure (DEE) because of the higher energy demands of the metabolic system in rest. The second hypothesis predicts a trade-off between different body functions, with a reduction of the BMR as a way to compensate for increased daytime energetic expenditure. We experimentally manipulated the workload of wild pied flycatchers by adding or removing chicks when chicks were 2 and 11 days old. We then measured the feeding frequency (FF), DEE and BMR at day 11, allowing us to assess both short- and long-term effects of increased workload. The manipulation at day 2 caused an increase in FF when broods were enlarged, but no response in DEE or BMR, while the manipulation at day 11 caused an increase in FF, no change in DEE and a decrease in BMR in birds with more chicks. Our results suggest that pied flycatchers adjust their workload but that this does not lead to a higher BMR at night (no support for the increased-intake hypothesis). In the short-term we find that birds reallocate energy with a consequent reduction of BMR (evidence for the compensation hypothesis). Birds thus resort to short-term strategies to increase energy expenditure, which could explain why energy expenditure and hard-work are not always correlated in birds.

IntroductionThe International Cancer Benchmarking Partnership (ICBP) identified significant international differences in lung cancer survival. Differing levels of comorbid disease across ICBP countries has been suggested as a potential explanation of this variation but, to date, no studies have quantified its impact. This study investigated whether comparable, robust comorbidity scores can be derived from the different routine population-based cancer data sets available in the ICBP jurisdictions and, if so, use them to quantify international variation in comorbidity and determine its influence on outcome.MethodsLinked population-based lung cancer registry and hospital discharge data sets were acquired from nine ICBP jurisdictions in Australia, Canada, Norway and the UK providing a study population of 233 981 individuals. For each person in this cohort Charlson, Elixhauser and inpatient bed day Comorbidity Scores were derived relating to the 4–36 months prior to their lung cancer diagnosis. The scores were then compared to assess their validity and feasibility of use in international survival comparisons.ResultsIt was feasible to generate the three comorbidity scores for each jurisdiction, which were found to have good content, face and concurrent validity. Predictive validity was limited and there was evidence that the reliability was questionable.ConclusionThe results presented here indicate that interjurisdictional comparability of recorded comorbidity was limited due to probable differences in coding and hospital admission practices in each area. Before the contribution of comorbidity on international differences in cancer survival can be investigated an internationally harmonised comorbidity index is required.

Objectives To compare patterns of care and peri-operative outcomes of robot-assisted radical prostatectomy (RARP) with other surgical approaches, and to create an economic model to assess the viability of RARP in the public case-mix funding system. Patients and Methods We retrospectively reviewed all radical prostatectomies (RPs) performed for localized prostate cancer in Victoria, Australia, from the Victorian Admitted Episode Dataset, a large administrative database that records all hospital inpatient episodes in Victoria. The first database, covering the period from July 2010 to April 2013 (n = 5 130), was used to compare length of hospital stay (LOS) and blood transfusion rates between surgical approaches. This was subsequently integrated into an economic model. A second database (n = 5 581) was extracted to cover the period between July 2010 and June 2013, three full financial years, to depict patterns of care and make future predictions for the 2014–2015 financial year, and to perform a hospital volume analysis. We then created an economic model to evaluate the incremental cost of RARP vs open RP (ORP) and laparoscopic RP (LRP), incorporating the cost-offset from differences in LOS and blood transfusion rate. The economic model constructs estimates of the diagnosis-related group (DRG) costs of ORP and LRP, adds the gross cost of the surgical robot (capital, consumables, maintenance and repairs), and manipulates these DRG costs to obtain a DRG cost per day, which can be used to estimate the cost-offset associated with RARP in comparison with ORP and LRP. Economic modelling was performed around a base-case scenario, assuming a 7-year robot lifespan and 124 RARPs performed per financial year. One- and two-way sensitivity analyses were performed for the four-arm da Vinci SHD, Si and Si dual surgical systems (Intuitive Surgical Ltd, Sunnyvale, CA, USA). Results We identified 5 581 patients who underwent RP in 20 hospitals in Victoria with an open, laparoscopic or robot-assisted surgical approach in the public and private sector. The majority of RPs (4 233, 75.8%), in Victoria were performed in the private sector, with an overall 11.5% decrease in the total number of RPs performed over the 3-year study period. In the most recent financial year, 820 (47%), 765 (44%) and 173 patients (10%) underwent RARP, ORP and LRP, respectively. In the same timeframe, RARP accounted for 26 and 53% of all RPs in the public and private sector, respectively. Public hospitals in Victoria perform a median number of 14 RPs per year and 40% of hospitals perform

Summary Background Prognostic information can rationalise clinical follow-up after radical cancer treatment. This retrospective cohort study of radical head and neck (chemo)radiotherapy patients examines the clinical safety and cost implications of stratifying follow-up intensity by post-treatment 18 FDG-PET-CT response. Methods In 2008 clinical review after radical head and neck radiotherapy was reduced from 3- to 6-monthly for patients with complete 18 FDG-PET-CT response at 3 months. 184 patients treated after this change (“PET Stratified”, 2009–11) were compared to 178 patients treated before (“Standard”, 2005–7). Clinical safety was assessed by the time to detection of recurrence, overall survival and potential for radical treatment of recurrence. A hospital cost analysis was performed using individual patient data. Results 127 of 178 Standard and 148 of 184 PET Stratified patients achieved complete response on post-treatment imaging. Baseline clinical characteristics were comparable. Median follow-up from response assessment was 4.8 years in the Standard cohort and 2.1 years for PET Stratified. PET Stratified patients had a mean 4.4 outpatient visits in 2 years, compared to 7.0 among Standard patients. Over 90% of patients remained free of recurrence at 2 years in both cohorts. Time to detection of recurrence was similar between two cohorts (HR1.05, 95%CI 0.45–2.52), as was overall survival (HR0.91, 95%CI 0.36–2.29). The proportion of radically treatable recurrences was also similar (42% Standard vs. 47% PET Stratified). The hospital cost savings per patient from reduced review were AUD$2606 over 2 years, AUD$5012 over five. Conclusion 18 FDG-PET-CT to stratify follow-up intensity after radical radiotherapy for head and neck cancer reduces costs with no apparent clinical detriment.

Objective To compare the recovery of urinary continence (UC) after robot-assisted radical prostatectomy (RARP) in men aged ≥70 and

Background In Australia, robotic-assisted radical prostatectomy (RARP) has steadily replaced open and laparoscopic surgery in the management of localized prostate cancer. Given the increased cost of this technology, we aimed to compare the perioperative, pathological, oncological and functional outcomes as well as short-term complications of laparoscopic and RARP. Methods We performed a retrospective review of prospectively collected data on 200 consecutive patients during the transition of a single surgeon (DM) from pure laparoscopic (n = 100) to RARP (n = 100) between September 2007 and March 2011. Results Median operative time and estimated blood loss were the same for both surgical approaches, 195 min (P = 0.29) and 300 mL (P = 0.88) respectively. Median length of hospital stay was shorter for RARP (P = 0.003). Complication rates were not statistically different between groups. There was no significant difference in positive surgical margin rates in pT2 (P = 0.36) or pT3 disease (0.99) or biochemical recurrence rate between groups (P = 0.14). The 12 months continence rate was improved with RARP compared with laparoscopic radical prostatectomy (93% versus 82%; P = 0.025). The potency rate was 56% and 74% at 12 months after laparoscopic radical prostatectomy and RARP respectively (P = 0.12) for a bilateral nerve sparing procedure. Conclusion We conclude from our single-surgeon comparative series that the robotic approach results in a significantly shorter length of hospital stay and improved 12 months continence rates and demonstrated a trend towards better potency rates. Complications, positive surgical margin rates and the requirement for adjuvant therapy are all improved with the robotic approach but did not show statistically significant differences.

The majority of melanomas are thin lesions with an excellent prognosis; however, significant tumor heterogeneity exists, and a small percentage of patients with early-stage disease may progress to metastatic recurrence. This study aimed to assess whether prognostic factors previously shown to be significant in predicting stage I and stage II melanoma recurrence were consistent in a large prospectively collected patient cohort, and to identify novel prognostic factors associated with early recurrence to inform follow-up protocols. There were 1029 patients with stage I and stage II melanoma included in the analysis, of whom 123 developed a recurrence during follow-up (median 2.13 years). Multivariable analysis identified ulceration, presence of mitoses, Clark level, presence of lymphovascular invasion, and a history of autoimmune disease as factors independently associated with recurrence. These data identified patients with stage I-II melanoma with very low-risk for recurrence: no ulceration, zero mitoses, a low Clark level, no lymphovascular invasion, and possibly no history of autoimmune disease. These patients do not require intensive follow-up: 12 monthly reviews and full skin checks may be appropriate. Ongoing research into prognostic factors for recurrence in early-stage melanoma is important.

In many bird populations, variation in the timing of reproduction exists but it is not obvious how this variation is maintained as timing has substantial fitness consequences. Daily energy expenditure (DEE) during the egg laying period increases with decreasing temperatures and thus perhaps only females that can produce eggs at low energetic cost will lay early in the season, at low temperatures. We tested whether late laying females have a higher daily energy expenditure during egg laying than early laying females in 43 great tits (Parus major), by comparing on the same day the DEE of early females late in their laying sequence with DEE of late females early in their egg laying sequence. We also validated the assumption that there are no within female differences in DEE within the egg laying sequence. We found a negative effect of temperature and a positive effect of female body mass on DEE but no evidence for differences in DEE between early and late laying females. However, costs incurred during egg laying may have carry-over effects later in the breeding cycle and if such carry-over effects differ for early and late laying females this could contribute to the maintenance of phenotypic variation in laying dates.

Climate change has profound ecological effects in birds, with the clearest effect a shift in timing, or phenology, of avian reproduction. To assess the consequences of these shifts, we performed a literature search and compared the rates of phenological change in the reproduction of birds with that of the food for their offspring. While in some areas the rate of change of the birds and their food was similar, there were also areas where the birds’ shift lagged behind that of their food. In these cases, this will lead to a phenological mismatch, which will affect the fitness of the brood. There are two hypotheses explaining why climate change leads to mismatched reproduction: either the cues used no longer accurately predict the peak in food abundance (the cues hypothesis) or the fitness costs of egg production and/or incubation of laying early enough to match reproduction are substantial in early spring and are not compensated by the fitness benefits of a better matched reproduction (constraint hypothesis). In the latter case, the phenological mismatch is adaptive. We present a simple mathematical model to show that this may be the case if there are fitness costs of egg laying and/or incubation under cold conditions and if the temperatures that determine the peak in food abundance increase stronger than the temperatures affecting the costs of egg laying and incubation, as is the case in the Netherlands. Whether or not a phenological mismatch is adaptive has important consequences for natural selection acting on timing of reproduction. If the mismatch is not adaptive, timing of reproduction will be under direct natural selection, while, if the mismatch is adaptive, selection is likely to be on the costs of egg production, possibly on egg size or adult size. In all cases, a mismatch is expected to have negative population consequences and, especially when the mismatch is adaptive, these consequences cannot be reduced by a response to natural selection on timing directly. This makes experimental studies on laying date, which can determine whether the mismatch is adaptive, of crucial importance.

The physiological condition of female birds during the egg-laying and incubation periods is of considerable interest and yet is relatively understudied in wild birds, primarily due to the difficulty of catching birds during this period without causing nest desertion. We therefore developed a box-net to capture cavity-nesting birds using sections of a mist-net placed around a metal cubic frame. We captured female Great Tits (Parus major) as they left nest boxes during the egg-laying and incubation periods and measured desertion rates. Using box-nets, we captured 108 of 119 (90%) females during egg laying and 10 of 12 (83%) during incubation. Our recapture rate over two consecutive days during incubation was 50% (5 of 10). Females not captured left nest boxes before we attempted to capture them, escaped through a hole in the mist-net, or remained in nest boxes for more than 2 h, after which we ended capture attempts. Overall, 22% of egg-laying females deserted, with desertion rates highest early in the egg-laying period. Desertion rates of females captured using box-nets did not differ from those of undisturbed females. One of 10 females captured in a box-net deserted during the incubation period. Box-nets are portable, can be set up and taken down quickly and easily, and could potentially be used with nest boxes or natural cavities at any height. Box-nets are easy to construct and adaptable for use with an array of cavity-nesting birds, and can be an important tool for studying female physiology during egg laying and incubation.

Summary 1. Climate change has caused a phenological mismatch between the timing of reproduction and the local food peak in many bird species. Late breeding birds therefore experience reduced food availability during chick rearing and are thus predicted to have an increased energy expenditure. Observational studies, however, show mixed results, perhaps because they compare energy expenditure across rather than within individuals at different levels of food availability. 2. In a cross foster experiment, we measured daily energy expenditure (DEE) twice within individuals during chick feeding (when chicks were 6 and 14 days old) for 28 free-living female great tits (Parus major). To avoid confounding effects of chick age, these females reared on both occasions a standardized foster brood of eight 10-day-old chicks during the 24-h measuring period. For all birds, food availability declined between the two measurements. 3. We show that DEE during chick feeding increased within females when food availability decreased. Variation in DEE within females is partly explained by brood visit rates, food availability and temperature. 4. DEE during chick feeding could be affected by the investment in previous stages of the reproductive attempt. However, energy expenditure during chick feeding was not correlated to energy expenditure during egg laying, measured in these same females. 5. Understanding of energetic costs during all phases of the reproductive cycle is important to forecast the consequences of climate warming on timing of reproduction.

In the original publication of the article, the concluding paragraph of the Discussion section was inadvertently missed and is provided below.

Provisioning visits by helpers are normally assumed to confer positive fitness effects on nestlings, but few studies have actually examined the nutritional value of items helpers fed to offspring. In the cooperatively breeding bell miner, Manorina melanophrys, helpers deliver large proportions of 'lerp', a sugary secretion of psyllids (Hemiptera; Psyllidae). Although lerp is a major food type of adults, its nutritional value is uncertain, especially since nestlings in other nectarivorous species are usually fed only protein-rich arthropods. Helpers in this system are predominantly male and are often unrelated to broods they aid, suggesting helping might be a sexual display, with any nutritional benefits to nestlings being of secondary importance. Detailed observations revealed that the proportion of lerp delivered increased with nestling age, but that it did not differ between helpers and parents, or between related and unrelated helpers. Variation in delivered biomass (lerp+arthropods) had a positive effect on nestling condition, but variation in the proportion of prey constituted by lerp had no measurable effect on nestling mass or condition. Finally, the total amount of food, nestling body mass and condition were all positively related to the number of helpers provisioning broods. These results are consistent with helping in bell miners operating as cooperative investment in brood fitness. Given that lerp was as effective as invertebrate prey in promoting growth, these results also suggest a valid nutritional role for this easily procured food, presumably facilitated by the unusually early development of nestling digestive tracts to utilize these simple sugars. (C) 2009 The Association for the Study of Animal Behaviour. Published by Elsevier Ltd. All rights reserved.

Research on cooperative breeding has begun to focus on direct fitness benefits gained by helpers, particularly when individuals are unrelated to those they assist. There has been considerable interest in helping possibly operating as a signal, either to show off individual quality to potential mates ('social prestige') or to ensure group membership ('pay to stay'). However, empirical investigation of these phenomena remains sparse. Here we investigate the potential for signalling via provisioning behaviour in the bell miner, Manorina melanophrys, an obligate cooperative breeding species in which the predominantly male helpers are commonly unrelated to breeders. Aggression between birds was extremely rare, and there was little to indicate a pay to stay system. The presence versus absence of members of the breeding pair as a potential audience at the nest had little influence on helper behaviour ( e. g. load size/composition, visit duration or frequency). Helpers did produce more individually distinctive vocalizations when in the presence of another helper or the breeding male, although presence of the breeding female ( a likely target of male signals) surprisingly had no effect. There was also evidence that nest arrival times coincided somewhat. These results are probably best explained by the helpers and breeding males being involved in additional cooperative behaviours when away from the nest, such as mobbing. Overall, there does not appear to be any evidence that bell miner helpers use nestling provisioning to signal their quality and/or work rate to one another or to either member of the breeding pair. (C) 2007 The Association for the Study of Animal Behaviour. Published by Elsevier Ltd. All rights reserved.

Management of rectal cancer has become multidisciplinary and is driven by the stage of the disease, with increased focus on restaging rectal cancer after neoadjuvant therapy.The purpose of this study was to assess the relative impact of restaging after preoperative chemoradiation with FDG-PET scan, CT, and MRI in the management of patients with rectal cancer.This was a retrospective study from a single institution.This study was conducted at a tertiary cancer center.A total of 199 patients met the inclusion criteria: patients with rectal adenocarcinoma; staged with positron emission tomography, CT, and MRI; T2 to T4, N0 to N2, M0 to M1; treated with neoadjuvant chemoradiation 50.4 Gy and infusional 5-fluorouracil; and restaged 4 weeks after chemoradiation before surgery between 2003 and 2013.Comparisons of the tumor stage among different imaging modalities before and after neoadjuvant chemoradiation were performed. The impact of restaging on the management plan was assessed.The stage at presentation was T2, 8.04%; T3, 65.33%; T4, 26.63%; N0, 17.09%; N1, 47.74%; N2, 34.67%; M0, 81.91%; and M1, 18.09%. Changes in disease stage postneoadjuvant chemoradiation were observed in 99 patients (50%). The management plans of 29 patients (15%) were changed. The impact of each restaging modality on management for all of the patients was positron emission tomography, 11%; CT, 4%; and MRI, 4%. In patients with metastatic disease at primary staging, the relative impact of each restaging modality in changing management was positron emission tomography, 32%; CT, 18%; and MRI, 6%.This study was limited by its single-center and retrospective design. Operations were performed 4 weeks after restaging.Changes in the extent of disease after long-course chemoradiotherapy result in changes of management in a significant percentage of patients. Positron emission tomography has the most significant impact in the change of management overall, and its use in restaging advanced rectal cancer should be further explored.

Bird breeding and spring migration phenology have advanced in response to climate change, but the effects differ between sites. Here, we examine the geographical variation in laying-date trends in a short-distance migrant, the European starling Sturnus vulgaris, and a long-distance migrant, the pied flycatcher Ficedula hypoleuca. We model the trend in laying date for these 2 species -between 1980 and 2004 for most of their European breeding areas -by combining geographical variation in mean laying date, the effect of temperature on laying date, and spatial variation in temperature change. Starlings are predicted to have advanced breeding over most of their range, with the greatest advance in north-eastern Europe. In contrast, pied flycatchers have delayed their laying in northern Europe, but have advanced their laying in western and central Europe. The species differ because pied flycatchers lay their eggs 25 d later at each site than starlings, and temperatures during these 2 periods show different trends. Temperatures during migration have also changed differently for populations heading to different breeding areas. This was most pronounced for pied flycatchers; northern populations experience an increase in temperatures during migration, while more southern populations presently still migrate at temperatures similar to those experienced 25 yr ago. As a consequence the southern population may be constrained in adapting to climate change by low temperatures during migration. There is a large contrast in how circumstances during migration and at the breeding grounds have changed: populations that advanced breeding most were subjected to the lowest temperature increases during migration. The temporal and spatial variation in temperature change has important consequences on how migrants adapt to ongoing climate change.

To compare the recovery of urinary continence (UC) after robot-assisted radical prostatectomy (RARP) in men aged ≥70 and70 years at 1-year follow-up and to assess for preoperative predictors of UC recovery, as older, healthy men with localised prostate cancer are often denied curative surgical treatment on the grounds of worse UC recovery.In all, 262 patients with prostate cancer having undergone RARP between May 2008 and September 2012, under the care of two consultant urological surgeons at three Melbourne hospitals, were identified. Patients were categorised based on their age ≥70 and70 years and compared with regards to two endpoints; percentage fully continent and mean pads/day at 4-6 weeks, and 3, 6, 9 and 12 months after RARP.Of the 262 men, 9% (24) were aged ≥70 years. Older men had higher PSA levels (P = 0.007) and clinical stages (P0.001) compared with the younger cohort. There were more non-nerve sparing procedures in the older group (P = 0.009) and a shorter mean operative time (P = 0.004). At 4-6 weeks after RARP, the number of pads used per day was greater in older men (P = 0.03) and there was a trend towards fewer older men being fully continent (P = 0.08) than their younger counterparts; however, by 3 months and all time-points thereafter there was no difference. The 12-month UC rates were 89% and 92% for men aged70 and ≥70 years, respectively. Neither age, body mass index, D'Amico risk group, nerve sparing nor use of Rocco suture were predictors of time to UC recovery.UC recovery after RARP in men aged ≥70 years appears comparable to younger men and therefore not a reason to deny older men with a reasonable life-expectancy curative surgical treatment of localised prostate cancer.

To ascertain the rate, type, significance, trends and the potential risk factors associated with radiotherapy incidents in a large academic department.Data for all radiotherapy activities from July 2001 to January 2011 were reviewed from radiotherapy incident reporting forms. Patient and treatment data were obtained from the radiotherapy record and verification database (MOSAIQ) and the patient database (HOSPRO). Logistic regression analyses were performed to determine variables associated with radiotherapy incidents.In that time, 65,376 courses of radiotherapy were delivered with a reported incident rate of 2.64 per 100 courses. The rate of incidents per course increased (1.96 per 100 courses to 3.52 per 100 courses, p0.001) whereas the proportion of reported incidents resulting in5% deviation in dose (10.50 to 2.75%, p0.001) had decreased after the introduction of an online electronic reporting system. The following variables were associated with an increased rate of incidents: afternoon treatment time, paediatric patients, males, inpatients, palliative plans, head-and-neck, skin, sarcoma and haematological malignancies. In general, complex plans were associated with higher incidence rates.Radiotherapy incidents were infrequent and most did not result in significant dose deviation. A number of risk factors were identified and these could be used to highlight high-risk cases in the future. Introduction of an online electronic reporting system resulted in a significant increase in the number of incidents being reported.

Purpose To report the local recurrence rate and late toxicity of intraoperative radiation therapy (IORT) boost to the tumor bed using the Intrabeam System followed by external-beam whole-breast irradiation (WBI) in women with early-stage breast cancer in a prospective single-institution study. Methods and Materials Women with breast cancer ≤3 cm were recruited between February 2003 and May 2005. After breast-conserving surgery, a single dose of 5 Gy IORT boost was delivered using 50-kV x-rays to a depth of 10 mm from the applicator surface. This was followed by WBI to a total dose of 50 Gy in 25 fractions. Patients were reviewed at regular, predefined intervals. Late toxicities were recorded using the Radiation Therapy Oncology Group/European Organization for Research and Treatment of Cancer Late Radiation Morbidity Scoring systems. Results Fifty-five patients completed both IORT boost and external-beam WBI. Median follow-up was 3.3 years (range, 1.4-4.1 years). There was no reported locoregional recurrence or death. One patient developed distant metastases. Grade 2 and 3 subcutaneous fibrosis was detected in 29 (53%) and 8 patients (15%), respectively. Conclusions The use of IORT as a tumor bed boost using kV x-rays in breast-conserving therapy was associated with good local control but a clinically significant rate of grade 2 and 3 subcutaneous fibrosis.

Indirect fitness benefits from kin selection can explain why non-breeding individuals help raise the young of relatives. However, the evolution of helping by non-relatives requires direct fitness benefits, for example via group augmentation. Here, we examine nest visit rates, load sizes and prey types delivered by breeding pairs and their helpers in the cooperatively breeding bell miner ( Manorina melanophrys ). In this system, males remain in their natal colony while young females typically disperse, and helpers of both sexes often assist at multiple nests concurrently. We found extremely clear evidence for the expected effect of genetic relatedness on individual helping effort per nest within colonies. This positive incremental effect of kinship was facultative—i.e. largely the result of within-individual variation in helping effort. Surprisingly, no sex differences were detectable in any aspect of helping, and even non-relatives provided substantial aid. Helpers and breeders of both sexes regulated their provisioning effort by responding visit-by-visit to changes in nestling begging. Helping behaviour in bell miners therefore appears consistent with adaptive cooperative investment in the brood, and kin-selected care by relatives. Similar investment by ‘unrelated’ helpers of both sexes argues against direct fitness benefits, but is perhaps explained by kin selection at the colony level.

516 Background: PIK3CA mutations (mt) are frequently observed in BC but their clinical relevance is unclear. We performed an individual pt data pooled-analysis to evaluate the prognostic impact of ...

9003 Background: In the modern era of melanoma treatment, approaches to imaging surveillance following surgery require reconsideration. The aim of this study was to evaluate disease sub-stage speci...