Disruption, discontinuity and a licence to live: Responding to cancer diagnoses.

Although a diagnosis of a life-limiting cancer is likely to evoke emotions, such as fear, panic and anxiety, for some people it can also provide an opportunity to live life differently. This article is based on research undertaken in Aotearoa New Zealand on the topic of exceptional cancer trajectories. Eighty-one participants who had been identified as living with a cancer diagnosis longer than clinically expected were interviewed, along with 25 people identified by some of the participants as supporters in their journey. For some participants the diagnosis provided the opportunity to rethink their lives, to undertake lifestyle and consumption changes, to be culturally adventurous, to take up new skills, to quit work and to change relationships with others. The concepts of biographical disruption and posttraumatic growth are considered in relation to these accounts, and it is argued that the event of a cancer diagnosis can give license for people to breach social norms.

Understanding disparities in post-operative mortality for Indigenous patients.

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

Regional variation in post-operative mortality in New Zealand.

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

Patient volume and clinical outcome after pancreatic cancer resection: A contemporary systematic review and meta-analysis.

BACKGROUND: Pancreatic cancer remains a highly fatal disease with a 5-year overall survival of less than 10%. In seeking to improve clinical outcomes, there is ongoing debate about the weight that should be given to patient volume in centralization models. The aim of this systematic review is to examine the relationship between patient volume and clinical outcome after pancreatic resection for cancer in the contemporary literature. METHODS: The Google Scholar, PubMed, and Cochrane Library databases were systematically searched from February 2015 until June 2021 for articles reporting patient volume and outcomes after pancreatic cancer resection. RESULTS: There were 46 eligible studies over a 6-year period comprising 526,344 patients. The median defined annual patient volume thresholds varied: low-volume 0 (range 0-9), medium-volume 9 (range 3-29), high-volume 19 (range 9-97), and very-high-volume 28 (range 17-60) patients. The latter 2 were associated with a significantly lower 30-day mortality (P < .001), 90-day mortality (P < .001), overall postoperative morbidity (P = .005), failure to rescue rate (P = .006), and R0 resection rate (P = .008) compared with very-low/low-volume hospitals. Centralization was associated with lower 30-day mortality in 3 out of 5 studies, while postoperative morbidity was similar in 4 out of 4 studies. Median survival was longer in patients traveling greater distance for pancreatic resection in 2 out of 3 studies. Median and 5-year survival did not differ between urban and rural settings. CONCLUSION: The contemporary literature confirms a strong relationship between patient volume and clinical outcome for pancreatic cancer resection despite expected bias toward more complex surgery in high-volume centers. These outcomes include lower mortality, morbidity, failure-to-rescue, and positive resection margin rates.

Anaesthetic choice for hip or knee arthroplasty in New Zealand: Risk of postoperative death and variations in use.

Anaesthetic choice for large joint surgery can impact postoperative outcomes, including mortality. The extent to which the impact of anaesthetic choice on postoperative mortality varies within patient populations and the extent to which anaesthetic choice is changing over time remain under-explored both internationally and in the diverse New Zealand context. In a national study of 199,211 hip and knee replacement procedures conducted between 2005 and 2017, we compared postoperative mortality among those receiving general, regional or general plus regional anaesthesia. Focusing on unilateral (n=86,467) and partial (n=13,889) hip replacements, we assessed whether some groups within the population are more likely to receive general, regional or general plus regional anaesthesia than others, and whether mortality risk varies depending on anaesthetic choice. We also examined temporal changes in anaesthetic choice over time. Those receiving regional alone or general plus regional for unilateral hip replacement appeared at increased risk of 30-day mortality compared to general anaesthesia alone, even after adjusting for differences in terms of age, ethnicity, deprivation, rurality, comorbidity, American Society of Anesthesiologists physical status score and admission type (e.g. general plus regional: adjusted hazard ratio (adj. HR)=1.94, 95% confidence intervals (CI) 1.32 to 2.84). By contrast, we observed lower 30-day mortality among those receiving regional anaesthesia alone compared to general alone for partial hip replacement (adj. HR=0.86, 95% CI 0.75 to 0.97). The latter observation contrasts with declining temporal trends in the use of regional anaesthesia alone for partial hip replacement procedures. However, we recognise that postoperative mortality is one perioperative factor that drives anaesthetic choice.

Disparities in post-operative mortality between Maori and non-Indigenous ethnic groups in New Zealand.

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

Atypical case of Crohn's colitis in a patient with adult-onset Still's disease.

A 65-year-old woman with a background of adult-onset Still's disease (AOSD) presented acutely to a general surgical unit with signs of bowel obstruction and sepsis. A CT scan was indicative of a mesenteric lymphadenopathy suspicious of malignancy. At the time of the surgery, a clinical diagnosis of lymphoma was made given the large number of lymph nodes; however, histological diagnosis was resulted as Crohn's colitis. There is only one other case of AOSD and Crohn's disease in the literature, and there is no clear pathological connection between the two inflammatory conditions. This case highlights the surgical management of an unusual presentation.

Perceptions of competency with evidence-based medicine among medical students: changes through training and alignment with objective measures.

AIMS: To identify whether medical students' self-perception of competence with evidence-based medicine (EBM) increases throughout their senior years of medical training. Furthermore, to identify whether their self-perception aligns with their true competence measured using a validated tool. This investigation also outlines whether students report observation of and participation in the process of EBM in clinical practice. METHODS: A cross-sectional survey was undertaken with a convenience sample of medical students in their fourth, fifth and sixth years of training at one campus site of Otago Medical School between February and April 2018. Self-perceived competence with EBM was measured using a 10-item questionnaire. True competence was measured using the Assessing Competency in Evidence-Based Medicine (ACE) tool. Students were asked to self-report their observation of and participation in the process of EBM in clinical settings. RESULTS: Out of 99 students invited to participate, we received a response rate of 97%. Participants included 37 fourth-year, 32 fifth-year and 27 sixth-year students. Mean self-perceived EBM competence was higher in sixth-year compared to fourth-year students. True competence was not significantly different between year groups. Medical students reported little observation of EBM in clinical settings, and few students reported to have participated in the process of EBM during clinical encounters. CONCLUSION: The lack of explicit role modelling of EBM in clinical environments may be a barrier to students improving EBM competence in the senior years of medical training.

Operative experience in essential emergency general surgery procedures: is autonomy achievable during surgical training?

BACKGROUND: Readiness for practice is an ongoing concern in surgery. Surgeons who have completed general surgery training are expected to be proficient in performing common emergency procedures. The aim of this study was to assess the experience and autonomy of general surgery trainees in New Zealand in 10 emergency general surgery procedures, and identify factors associated with reaching primary operator (PO) thresholds. METHODS: Operative logbook data from all New Zealand general surgery trainees from 2013 to 2017 were analysed. Data for 10 emergency general surgery procedures were extracted to determine PO and autonomous PO (mentor not scrubbed) rates. A threshold of 70% for PO and APO rates was used to define two levels of proficiency. RESULTS: A total of 120 trainees performed 40 865 included procedures. Trainees met the PO threshold for all procedures by Surgical Education and Training (SET) 5. The APO threshold was met for three of 10 procedures (appendicectomy, drainage of perianal abscess and perforated peptic ulcer repair). Final APO rates for the other procedures ranged from 18% to 58%. On multivariate analysis, SET year and case volume were associated with increased odds of meeting the PO and APO thresholds. Female trainees were less likely to reach the PO and APO thresholds for three of 10 and four of 10 procedures, respectively. CONCLUSION: Trainees had increasing PO and autonomous PO rates over the course of their training. Graduating New Zealand general surgeons likely have sufficient operative experience in emergency general surgery procedures. However, rates of autonomy are lower, and further research is needed to determine whether this affects readiness for independent practice.

Brief report: Lymph node morphology in stage II colorectal cancer.

BACKGROUND: Colorectal cancer is one of the leading causes of cancer-associated morbidity and mortality worldwide. The local anti-tumour immune response is particularly important for patients with stage II where the tumour-draining lymph nodes have not yet succumbed to tumour spread. The lymph nodes allow for the expansion and release of B cell compartments such as primary follicles and germinal centres. A variation in this anti-tumour immune response may influence the observed clinical heterogeneity in stage II patients. AIM: The aim of this study was to explore tumour-draining lymph node histomorphological changes and tumour pathological risk factors including the immunomodulatory microRNA-21 (miR-21) in a small cohort of stage II CRC. METHODS: A total of 23 stage II colorectal cancer patients were included. Tumour and normal mucosa samples were analysed for miR-21 expression levels and B-cell compartments were quantified from Haematoxylin and Eosin slides of lymph nodes. These measures were compared to clinicopathological risk factors such as perforation, bowel obstruction, T4 stage and high-grade. RESULTS: We observed greater Follicle density in patients with a lower tumour T stage and higher germinal centre density in patients with higher pre-operative carcinoembryonic antigen levels. Trends were also detected between tumours with deficiency in mismatch repair proteins, lymphatic invasion and both the density and size of B-cell compartments. Lastly, elevated tumour miR-21 was associated with decreased Follicle and germinal centre size. CONCLUSION: Variation in B-cell compartments of tumour-draining lymph nodes is associated with clinicopathological risk factors in stage II CRC patients.

A survey of neurosurgical management and prognostication of traumatic brain injury following the RESCUEicp trial.

PURPOSE: Decompressive craniectomy remains controversial because of uncertainty regarding its benefit to patients; this study aimed to explore current practice following the RESCUEicp Trial, an important study in the evolving literature on decompressive craniectomies. MATERIALS AND METHODS: Neurosurgeons in New Zealand, Australia, USA and Nepal were sent a survey consisting of two case scenarios and several multi-choice questions exploring their utilisation of decompressive craniectomy following the RESCUEicp Trial. RESULTS: One in ten neurosurgeons (n = 6, 10.3%) were no longer performing decompressive craniectomies for TBI following the RESCUEicp Trial and two fifths (n = 23, 39.7%) were less enthusiastic. Most neurosurgeons would not operate in the face of severe disability (n = 46, 79.3%) or vegetative state/death (n = 57, 98.3%). Neurosurgeons tended give more optimistic prognoses than the CRASH prognostic model. Those who suggested more pessimistic prognoses and those who use decision support tools were less likely to advise decompressive surgery. CONCLUSIONS: RESCUEicp has had a notable impact on neurosurgeons and their management of TBI. Although there remains no clear clinical consensus on the contraindications for decompressive craniectomy, most neurosurgeons would not operate if severe disability or vegetative state (the rates of which are increased by such surgery) seemed likely. Whilst unreliable, prognostic estimates still have an impact on clinical decision making and neurosurgical management. Wider use of decision support tools should be considered.

Postoperative mortality in New Zealand following general anaesthetic: demographic patterns and temporal trends.

OBJECTIVES: In this manuscript, we describe broad trends in postoperative mortality in New Zealand (a country with universal healthcare) for acute and elective/waiting list procedures conducted between 2005 and 2017. DESIGN, PARTICIPANTS AND SETTING: We use high-quality national-level hospitalisation data to compare the risk of postoperative mortality between demographic subgroups after adjusting for key patient-level confounders and mediators. We also present temporal trends and consider how rates in postoperative death following acute and elective/waiting list procedures have changed over this time period. RESULTS AND CONCLUSION: A total of 1 836 683 unique patients accounted for 3 117 374 admissions in which a procedure was performed under general anaesthetic over the study period. We observed an overall 30-day mortality rate of 0.5 per 100 procedures and a 90-day mortality rate of 0.9 per 100. For acute procedures, we observed a 30-day mortality rate of 1.6 per 100, compared with 0.2 per 100 for elective/waiting list procedures. In terms of procedure specialty, respiratory and cardiovascular procedures had the highest rate of 30-day mortality (age-standardised rate, acute procedures: 3-6 per 100; elective/waiting list: 0.7-1 per 100). As in other contexts, we observed that the likelihood of postoperative death was not proportionally distributed within our population: older patients, Maori patients, those living in areas with higher deprivation and those with comorbidity were at increased risk of postoperative death, even after adjusting for all available factors that might explain differences between these groups. Increasing procedure risk (measured using the Johns Hopkins Surgical Risk Classification System) was also associated with an increased risk of postoperative death. Encouragingly, it appears that risk of postoperative mortality has declined over the past decade, possibly reflecting improvements in perioperative quality of care; however, this decline did not occur equally across procedure specialties.

Reducing length of stay for patients presenting to general surgery with acute non-surgical abdominal pain.

BACKGROUND: Acute abdominal pain is a common surgical presentation. We previously found that over the last decade, more patients were admitted to hospital with non-surgical diagnoses (e.g. gastroenteritis, constipation and non-specific abdominal pain) and length of stay and use of imaging (mainly computed tomography scan) for these patients increased. This study aimed to reduce length of stay and use of imaging for patients admitted with non-surgical abdominal pain. METHODS: A prospective study was undertaken in a tertiary centre evaluating length of stay and use of additional imaging in patients with a non-surgical diagnosis after a quality improvement intervention was implemented. RESULTS: A total of 454 patients were included; 204 (44.9%) presented with non-surgical abdominal pain. During the study period, a significant reduction in computed tomography scan requests was observed (38.5-25.0%, P = 0.037) and an increasing proportion of these patients were discharged within 12 h (33.3-57.1%, P = 0.018). The number of re-presentations remained unchanged (P = 0.358). CONCLUSIONS: The study intervention increased the proportion of patients with non-surgical diagnoses that were successfully discharged within 12 h and reduced the use of additional imaging in this group. This may lead to improved use of health care resources for patients with more urgent diagnoses.

Circulating Extracellular Vesicle MicroRNA as Diagnostic Biomarkers in Early Colorectal Cancer-A Review.

Colorectal cancer (CRC) is one of the most common malignancies in the developed world, with global deaths expected to double in the next decade. Disease stage at diagnosis is the single greatest prognostic indicator for long-term survival. Unfortunately, early stage CRC is often asymptomatic and diagnosis frequently occurs at an advanced stage, where long-term survival can be as low as 14%. Circulating microRNAs encapsulated in extracellular vesicles (EVs) have recently come to prominence as novel diagnostic markers for cancer. EV-miRNAs are dysregulated in the circulation of CRC patients compared to healthy controls, and several specific miRNA candidates have been posited as diagnostic markers, including miR-21, miR-23a, miR-1246, and miR-92a. This review outlines the current landscape of EV-miRNAs as potential diagnostic markers for CRC, with a specific focus on those able to detect early stage disease.

Prognostic value of multiple cytokine analysis in colorectal cancer: a systematic review.

The link between inflammation and outcome has been established in colorectal cancer through experimental evidence demonstrating an influential role of pro-inflammatory cytokines on tumour growth and progression. Furthermore, prognostic scores based on overall markers of systemic inflammation such as C-reactive protein and neutrophil count have been validated. Over recent years, an increasing number of inflammatory cytokines have been identified as prognostic predictors in colorectal cancer and the aim of this review was to evaluate the literature on the prognostic value of multiple cytokine measurement. The English language literature published since the year 2000 was searched using terms including, 'colorectal cancer', 'cytokines' and 'prognosis' through Medline, Embase and Scopus databases. Reports were screened by two independent reviewers and studies evaluating fewer than three cytokines were excluded. Quality assessments were performed in six domains before data extraction was undertaken in duplicate. Seven studies were found to evaluate multiple cytokines after 570 records were screened. The quality of these studies ranged from poor to moderate and were heterogeneous in terms of the patient population and the number and selection of cytokines tested. Four studies combined multiple cytokine levels into a single score and found them to be predictive of prognosis whereas the association between individual cytokines and outcome was not demonstrated consistently. The combination of multiple cytokine markers into a single prognostic score shows promise in colorectal cancer and further research is required to establish and validate such a score.

Can Surgical Registrars Accurately Identify the Urgent from the Non-Urgent Patient Presenting with Acute Abdominal Pain?

BACKGROUND: Acute abdominal pain is a common surgical presentation with a wide range of causes. Differentiating urgent patients from non-urgent patients is important to optimise patient outcomes and the use of hospital resources. The aim of this study was to determine how accurately urgent and non-urgent patients presenting with abdominal pain can be identified. METHODS: A prospective study of consecutive patients admitted with abdominal pain was undertaken. Urgent patients were classified as requiring treatment (theatre, intensive care unit, endoscopy, or radiologic drainage) within 24 h. Differentiation between urgent and non-urgent was made on the basis of the initial assessment prior to the use of advanced imaging. Outcomes were compared to a final classification based on final diagnosis as adjudicated by an expert panel. RESULTS: Of the 301 patients included, 93 (30.9%) were deemed urgent based on initial assessment, compared to 83 (27.6%) on final diagnosis. Overall sensitivity for recognising urgent patients was 74.7% and specificity 89.9%, and overall accuracy was higher for senior registrars compared to junior registrars (p = 0.015). Urgent patients more often looked unwell or had peritonism on examination (39.8 vs. 17.4% and 56.6 vs. 14.7%, respectively, p < 0.001 for both). CONCLUSIONS: Registrars can accurately differentiate urgent from non-urgent patients with acute abdominal pain in the majority of cases. Accuracy was higher amongst senior registrars. The "end-of-the-bed-o-gram" and clinical examination are the most important features used for making this differentiation. This demonstrates that there is no substitute for exposure to acute presentations to improve a trainee's diagnostic skill.

Team-based musculoskeletal assessment and healthcare quality indicators: A systematic review.

The primary objective of this review was to describe health quality indicator (HQI) outcomes of team-based musculoskeletal (MSK) assessments aimed at directing patient care. Secondary objectives included determining the most commonly assessed HQIs, extent of team collaboration, and the healthcare practitioners that most commonly comprise MSK-assessment teams. This review was registered in the PROSPERO database and conducted according to PRISMA guidelines. Five databases were systematically searched to August 2017. Studies selected met a priori inclusion criteria and investigated an HQI outcome of a primary or intermediate care MSK team-based assessment aimed at directing treatment. Two independent raters assessed study quality [Downs and Black (DB) criteria] and level of evidence (Oxford Centre of Evidence-Based Medicine model). Ten studies were included. The majority were low-quality [median DB score 14/32 (range 6-18)] pre-experimental studies (level 4 evidence). Heterogeneity in methodology and HQIs precluded meta-analyses. Hospital length-of-stay (LOS; 3/10 studies) and pain level (3/10) were the most common HQIs investigated. Teams (9/10) were most commonly comprised of a physiotherapist and another healthcare practitioner. Most teams (8/10) demonstrated low-levels of collaboration. There is limited low-level evidence to suggest that team-based MSK assessments are associated with improved clinical outcomes (i.e., pain, quality-of-life) and shorter LOS.

Factors associated with hospital admission in adult patients with asthma exacerbations: A systematic review.

OBJECTIVES: A variable proportion of patients presenting to the emergency department (ED) with acute asthma require admission to hospital. Previous studies have identified select factors associated with admission following ED presentation; however, no review has synthesized the evidence in this regard. This systematic review summarizes the evidence regarding factors associated with hospital admission following ED presentation. METHODS: Searches were conducted in seven electronic databases and common sources of grey literature. Studies reporting disposition for adults after ED presentation were included. Admission proportions and factors associated with hospitalization that remained statistically significant in multivariable analyses (p < 0.05) were reported. RESULTS: Out of an initial 5865 identified articles, 15 articles met full inclusion criteria and 11 were included in the analyses. Female sex (n = 2) and older age (n = 2) were individual factors associated with admission. Patient vital signs and severity followed by patient attributes were the two most frequent domains associated with admission. Admission proportions were analyzed in 10 studies at an median of ∼20% with no clear change between 1996 and 2012. CONCLUSIONS: Factors such as patient demographics (e.g., female sex, older age), patient vital signs/severity, and history are associated with admission following ED presentation for acute asthma. These can be employed by ED clinicians to effectively discern patients at high risk for admission and lead to more evidence-based decision-making.

Neoadjuvant therapy in rectal cancer: how are we choosing?

BACKGROUND: Neoadjuvant therapy has revolutionized the management of rectal cancer; however, there is a need to examine the factors driving neoadjuvant treatment allocation. This study aimed to describe patterns of treatment allocation for patients with rectal cancer at our institution and identify predictors for receiving neoadjuvant therapy, and for choice of short- or long-course therapy. METHODS: A retrospective review of a prospectively maintained database of 122 patients undergoing surgical resection for rectal cancer with curative intent, between 1 November 2012 and 31 October 2017. Univariate and multivariate analyses were performed to identify factors that determined which patients received neoadjuvant therapy, and whether it was short or long course. RESULTS: Eighty-six patients (70%) received neoadjuvant therapy. Independent predictors for receiving neoadjuvant therapy were T3-4 tumours (P < 0.001), node-positive disease (P = 0.005) and mid (P = 0.045) or low rectal cancers (P < 0.001). Of those receiving neoadjuvant therapy, 38 (44%) received short course and 48 (56%) received long course. Node-positive disease was the only predictor for receiving long rather than short-course neoadjuvant therapy (P = 0.002). Overall, these factors predicted 76% of neoadjuvant treatment allocation. Our predictor model identified important areas of variance in our decision-making. CONCLUSION: Utilizing the identified factors, it appears that consistent decisions regarding neoadjuvant therapy are being made the majority of the time. These decisions are largely driven by T and N stage as well as tumour height. Mesorectal fascia involvement, pre-treatment carcinoembryonic antigen, age and comorbidity also influenced decision-making to a lesser and more variable extent.

Pre-operative carcinoembryonic antigen predicts survival following colorectal cancer surgery with curative intent.

BACKGROUND: Circulating biomarkers may be of value in providing additional prognostic information to the TNM staging system. Previous population-level studies suggest a prognostic role for pre-operative carcinoembryonic antigen (CEA). The purpose of this study is to verify the prognostic role of pre-operative CEA at the individual level, in a New Zealand cohort of colorectal cancer patients. METHODS: Retrospective cohort study of patients undergoing potentially curative surgery for colorectal adenocarcinoma between 2010 and 2012 at a tertiary hospital in New Zealand. One hundred and thirty-nine patients had pre-operative CEA data available and were included in the study. The main outcomes measured were overall survival (OS) and disease-free survival (DFS) over a minimum of 5 years of follow up. RESULTS: Pre-operative CEA was requested in 138 out of 237 (58.2%) patients undergoing surgery. The median age was 71 years and median follow-up duration 61 months. High CEA was not associated with the incidence of disease recurrence (P = 0.69). A significant difference was found between high and low CEA for OS (P = 0.09) and DFS (P = 0.04). On multi-variate survival analysis, pre-operative CEA was identified as an independent predictor of OS (HR 2.50, 95% CI 1.17-5.36, P = 0.02) and DFS (HR 1.78, 95% CI 1.02-3.13, P = 0.04). CONCLUSION: We identified pre-operative CEA as an independent predictor of OS and DFS on an individual level. CEA offers additional prognostic value to TNM staging and should be requested routinely as part of the pre-operative work-up.