Kate Alexander

Background: Frailty has emerged as a critical determinant of postoperative risk in patients undergoing cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS + HIPEC). However, its impact on postoperative quality of life (QoL) remains underexplored. Therefore, this study aimed to evaluate the association between preoperative frailty and postoperative QoL in patients undergoing CRS + HIPEC. Methods: This retrospective cohort study included patients who underwent CRS + HIPEC at the Royal Prince Alfred Hospital between May 2017 and June 2024. Frailty was assessed using the Clinical Frailty Scale (CFS), with patients classified as frail (CFS ≥ 4) or non‐frail (CFS < 4). QoL outcomes were evaluated using the EuroQol 5‐Dimension 5‐Level (EQ‐5D‐5 L) and Short Form‐36 (SF‐36) Health Survey at five time points. Subgroup analyses were conducted based on age (< 65 vs. ≥ 65 years). Results: Of the 364 included patients, 49 (13.5%) were classified as frail. Frailty was significantly associated with poorer QoL outcomes, particularly in mobility, self‐care, usual activities, and physical component summary (PCS) scores (all p ≤ 0.003) at baseline. These impairments persisted at three and 6 months postoperatively. Pain and discomfort also emerged as significant issues for frail patients at both three‐ and 6‐months following surgery ( p = 0.018 and p = 0.005, respectively). Older frail patients (≥ 65 years) experienced significantly greater impairments in self‐care and usual activities at 6 months postoperatively, along with lower mental health summary (MCS) scores at 12 months compared to the non‐frail group. Conclusions: Preoperative frailty was significantly associated with poorer QoL outcomes following CRS + HIPEC, highlighting the importance of routine frailty screening and prehabilitation strategies to optimize outcomes in vulnerable patients.

Background: Preoperative mental wellbeing is an important determinant of postoperative recovery, yet psychological care is frequently overlooked within multidisciplinary prehabilitation programmes. When included, psychological interventions are fragmented and inconsistently delivered. This study aimed to establish international multidisciplinary consensus on preferred psychological prehabilitation interventions for patients undergoing urogenital, thoracic or gastrointestinal cancer surgery, and to describe current practice. Methods: A three‐round Delphi was conducted between February and September 2025. An international multidisciplinary expert panel rated the perceived effectiveness of each intervention for urogenital, thoracic and gastrointestinal cancer surgery using a 5‐point Likert scale. Predefined criteria classified interventions as effective, ineffective, contested or indeterminate. Round 1 also captured current models of psychological prehabilitation delivery. Results: In total, 439 participants completed Round 1, with 191 and 234 completing Rounds 2 and 3, respectively. Nine interventions reached consensus as endorsed across all tumour types, with supportive counselling, personalised coping strategies, cognitive behavioural therapy and mindfulness‐based techniques reaching the strongest agreement. Sexual health counselling was endorsed only for urogenital cancers. No interventions reached consensus as ineffective; however, hypnotherapy and eye movement desensitisation and reprocessing were contested in specific cancer groups, whilst metacognitive therapy remained indeterminate. International practice was heterogeneous, with limited routine screening, variable access to psychological services and funding/resource constraints as common barriers. Conclusion: This international Delphi study identified a core set of consensus‐based psychological prehabilitation interventions for cancer surgery, providing a foundation for clinical implementation. Future research should prioritise hybrid effectiveness‐implementation designs, generating data on optimal providers, delivery formats and patient characteristics.

Background: Pelvic exenteration (PE) is a radical surgery for advanced pelvic malignancies that carries substantial psychosocial impacts. Assessing distress is critical for timely support. Aims: To evaluate the responsiveness‐to‐change and convergent validity of the distress thermometer (DT), and to determine an optimal cutoff score for detecting clinically significant distress in a PE cohort. Methods: Secondary analyses of cohort study data involving adult patients who underwent PE at a quaternary referral hospital. Responsiveness was evaluated by determining whether the DT differentiated cases of decreased emotional well‐being and health‐related quality of life from pre‐ to post‐surgery, using the Functional Assessment of Cancer Therapy‐General (FACT‐G), FACT‐Colorectal, and Emotional Well‐Being (EWB) subscale as external criteria. Convergent validity was evaluated using the correlation between the DT and the EWB subscale scores. Cutoff scores were examined by reviewing the following indices, using an existing EWB cutoff as an external anchor: sensitivity, specificity, positive/negative predictive values, and clinical utility index (CUI). Results: The analysis included 377 patients (mean age: 61 years, 56% male; 41% recurrent rectal cancer). The DT demonstrated responsiveness, with AUCs > 0.7 for detecting emotional and quality‐of‐life decline post‐surgery. Convergent validity was demonstrated through a moderate correlation between the DT and the EWB subscale scores ( r _s = −0.56, p < 0.001). The optimal DT cutoff score was 4: Sensitivity; 87.0%, Specificity; 52.7%, CUI− value; 0.49 (ruling out cases: satisfactory utility), CUI+ value; 0.33 (case finding: poor utility). Conclusion: The DT is a valid and responsive tool for detecting psychological distress in PE patients. Its high sensitivity supports its use in routine screening.

Introduction: Gastrointestinal cancer surgery commonly leads to postoperative complications and other adverse outcomes. While prehabilitation shows promise in reducing adverse postoperative outcomes, most hospitals have resource limitations that preclude its use as standard of care. Additionally, the need to expedite surgery from diagnosis often creates a narrow window for prehabilitation initiatives. Online, self-reported screening tools may address these challenges by facilitating early identification of high-risk patients and enabling targeted preoperative interventions, thereby allowing equitable allocation of limited resources. Therefore, the primary aim of this study is to evaluate the predictive utility of a tri-modal (physical, nutritional, psychological) screening tool for patients undergoing gastrointestinal cancer surgery. Methods: This prospective international cohort study will recruit 1214 adults undergoing elective gastrointestinal cancer surgery across 35 sites from 19 countries. Participants will complete an online screening tool developed through a comprehensive, multistep, predefined process. The screening tool comprises the Duke Activity Status Index, Patient-Generated Subjective Global Assessment Short Form and the Patient Health Questionnaire-4, in English, Spanish, French or Portuguese. These tools were selected based on a scoping review, followed by an international Delphi consensus process. The primary outcomes include rate of postoperative complications, major complications (Clavien-Dindo Classification grade III–V) and overall complication severity assessed by the Comprehensive Complications Index; all assessed 30 days postoperatively. Secondary outcomes include hospital length of stay, readmission rate within 30 days, discharge destination (home vs other), days at home and alive in 30 days postsurgery, 30-day all-cause mortality and 12-month survival. Primary analyses will establish optimal screening tool cut-points to stratify patients into clinically actionable risk categories for postoperative complications and examine the independent predictive value of these screening scores after adjusting for established clinical risk factors. Ethics and dissemination: This study has received ethical approval from the Sydney Local Health District Human Research and Ethics Committee (X25-0333 and 2025/ETH02465) and has been registered on the Open Science Framework (10.17605/OSF.IO/HVCGD). The results of Preoperative Risk Evaluation for Cancer Treatment will be submitted to reputable journals and presented at national and international conferences.

Background: Gastrointestinal (GI) cancers are a major global health challenge due to their high incidence, mortality, and surgical complication rates. Preoperative physical, nutritional, and psychological vulnerabilities increase the risk of adverse surgical outcomes. Despite this, there is currently no validated, self‐report screening tool integrating assessment across all three domains. This scoping review aims to identify and describe existing preoperative screening tools used to assess modifiable physical, nutritional, and psychological domains in adult patients undergoing elective GI cancer surgery. Methods: We conducted this scoping review in accordance with Arksey and O'Malley's framework and PRISMA‐ScR guidelines. Searches were performed across MEDLINE, EMBASE, CINAHL, EBM, and PsycINFO date limited from January 2000 to March 2025. Studies were included if they evaluated preoperative screening tools for physical, nutritional, and/or psychological assessment in adult patients undergoing GI cancer surgery. Data on tool characteristics, domains assessed, administration time, and psychometric properties were extracted and synthesized descriptively. Results: From 2825 initial records, 121 studies were included, encompassing 77 unique screening tools. These were categorized as physical ( n = 21), nutritional ( n = 16), and psychological ( n = 40) tools. Most tools were brief (1–15 items). Conclusions: Although most screening tools are brief, feasible for self‐administration, and freely accessible, none integrated all three domains. Substantial heterogeneity in tools highlights the need for a comprehensive, validated multidomain preoperative screening tool for this population.

Background/Objectives: (P)rehabilitation, comprising structured exercise, nutritional optimisation, and/or psychological support delivered pre- or postoperatively, has demonstrated efficacy in improving outcomes across the cancer care continuum. However, access remains limited. Technology-enabled (p)rehabilitation offers a novel solution with the potential to enhance equity and continuity of care. This systematic review aimed to evaluate the efficacy of technology-enabled (p)rehabilitation on perioperative and patient-reported outcomes among individuals undergoing thoracic and/or abdominopelvic cancer surgery. Methods: Six databases were search from inception to October 2024. Eligible studies were randomised controlled trials (RCTs) comparing technology-enabled (p)rehabilitation with usual care, placebo, or non-technology-based interventions in adults undergoing thoracic and/or abdominopelvic cancer surgery. Outcomes included postoperative complications, hospital readmissions, hospital length of stay (LOS), quality of life (QoL), pain, anxiety, depression, fatigue, distress, and satisfaction. Higher scores indicated improved QoL or worse symptom severity. Risk of bias was assessed using the revised Cochrane tool, and evidence strength was determined using GRADE methodology. Relative risks (RR) and mean differences (MD) were calculated using random-effects meta-analysis. Results: Seventeen RCTs (18 publications, n = 1690) were included. Trials most commonly evaluated application-based platforms (n = 8) and the majority exhibited some risk of bias. Technology-enabled (p)rehabilitation was associated with a significant reduction in LOS (MD = 1.33 days; 95% CI: 0.59–2.07; seven trials), and improvements in pain (MD = 6.12; 95% CI: 3.40–8.84; four trials), depression (MD = 2.82; 95% CI: 0.65–4.99; five trials), fatigue (MD = 10.10; 95% CI: 6.97–13.23; three trials) and distress (MD = 1.23; 95% CI: 0.30–2.16; single trial) compared with controls. Conclusions: Technology-enabled (p)rehabilitation shows promise in reducing LOS and improving selected patient-reported outcomes following thoracic and abdominopelvic cancer surgery. Although evidence is limited due to the small number of studies, modest sample sizes, methodological heterogeneity, and intervention variability, the overall findings justify further investigation. Large-scale, adequately powered clinical trials are required to confirm efficacy and guide clinical effectiveness and implementation studies.

Background: Curative surgery for prostate cancer is uncommonly offered to patients aged ≥ 75, balancing functional outcomes against survival benefit. The increased adoption of robotic‐assisted radical prostatectomy (RARP) and improved overall life expectancy challenges this paradigm. The objective of this study was to compare functional outcomes between elderly and younger patients following RARP. Methods: Retrospective review of a prospective multicentre database including all RARP patients between October 2016 and December 2023. Patients were divided into cohorts based on age; elderly (≥ 75 years) and younger (< 75 years). Variables included baseline demographics (body mass index [BMI], American Society of Anaesthesiologists [ASA] classification, prostate specific antigen [PSA], and Gleason score), surgical (technique, complications, and length of stay), pathological (histopathology, margins, and PSA) and functional (incontinence, International Prostate Symptom Score [IPSS], International Index of Erectile Function [IIEF‐5], and Expanded Prostate Index Composite [EPIC]) outcomes. Univariate (chi‐square and t ‐tests) and multivariate analysis were performed to compare cohorts against the primary outcome of continence at 1‐year (number of pads/day), with p ‐values < 0.05 considered statistically significant. Results: A total of 397 patients were included (< 75; n = 332, ≥ 75; n = 65). No statistically significant differences were detected in continence at 1‐year in ≥ 75 (< 75; 0.73 [0.59–0.87], ≥ 75; 0.66 [0.37–0.95] mean pads/24 h, p = 0.8), despite significantly lower nerve preservation and bladder‐neck spare rates (< 75; 37.3%, ≥ 75; 21.5%). IIEF‐5 scores were worse in the ≥ 75 group (1.60 ± 1.17 vs. 5.73 ± 6.93 p < 0.001), however there were no significant differences in IPSS. Patient in the elderly cohort had more severe disease (67.7% T3, ≥ 75 vs. 47.3%, < 75, p < 0.05). Rates of positive surgical margins (28.3% vs. 30.8% [≥ 75]) and PSA recurrence (25% vs. 23% [≥ 75]) were similar. Complication rates were low in both groups with no significant differences (3% vs. 6.6% [≥ 75]) and were of lower severity in the ≥ 75 group. Conclusion: RARP in carefully selected elderly patients does not increase risk of urinary incontinence and should not be disregarded in an aging population with higher overall life expectancy.

Background: Research productivity is a key indicator of academic and clinical advancement in surgery. While previous studies have identified key drivers of productivity, comprehensive analyses examining the key determinants of research output across multiple Australian surgical departments remain limited. Methods: A cross‐sectional study was conducted analysing publicly available data from 16 surgical departments at Royal Prince Alfred (RPA) Hospital in December 2024. Data on researcher characteristics, including number of publications, citations, h‐index, higher degree by research (HDR) training, academic appointments, and international collaboration, were collated and aggregated for each department. Departmental research productivity was assessed through three primary outcomes: total publication count, aggregate citation count, and median h‐index. Univariate and multivariable logistic regression analyses were performed in RStudio to examine associations between these factors and departmental research productivity, measured by publication count, citation count, and median h‐index. Results: A total of 216 research members (148 consultants) were included. For publication count, univariate analyses showed significant associations with HDR training ( p = 0.016) and academic appointment level ( p = 0.048). In the multivariable model, only HDR training remained independently associated with publication count ( β = 8.31, 95% CI: 1.77–14.85, p = 0.016, R ² = 0.347). For h‐index, HDR training ( p = 0.027), academic appointment level ( p = 0.138), international qualification ( p = 0.039), and international collaboration ( p = 0.044) showed associations in univariate testing. In the multivariable model, both HDR training ( β = 0.29, 95% CI: 0.03–0.55, p = 0.030, R ² = 0.491) and international collaboration ( β = 0.47, 95% CI: 0.00–0.93, p = 0.048, R ² = 0.491) remained significant. No multivariable models constructed for citations met statistical significance. Conclusions: This study highlights HDR training as the most consistent predictor of surgical research productivity across multiple metrics across surgical departments in a tertiary Australian hospital. International collaboration emerges as an additional significant driver of research impact, as measured by h‐index. These findings provide evidence to support institutional investments in HDR training pathways and international collaborative networks as strategic approaches to enhance research culture and productivity in Australian surgical departments.