The wearable activity technology and action-planning trial in cancer survivors: Physical activity maintenance post-intervention.

OBJECTIVES: The study objective was to assess whether moderate-to-vigorous intensity physical activity (MVPA) change in cancer survivors (n = 68, mean age = 64 years) was maintained 12-weeks following the Wearable Activity Technology and Action Planning (WATAAP) intervention. Secondary aims were to assess the effects of the intervention on blood pressure (BP) and body mass index (BMI), and to explore group differences between baseline and 24-weeks. DESIGN: Randomized controlled trial. METHODS: MVPA and sedentary behaviour were assessed using an accelerometer at baseline, the end of the intervention (12-weeks), and at 24-weeks. Generalised linear mixed models with random effects were used to examine between-group and within-group changes in MVPA, sedentary behaviour, BP and BMI. RESULTS: MVPA was significantly higher in the intervention group compared with the control group at 24-weeks following adjustment for known confounders (141.4 min/wk. (95% CI = 9.1 to 273.8), p = 0.036). At 24-weeks participants in the intervention group had maintained their increased levels of MVPA (change from 12-weeks = 8.8 min/wk.; 95% CI = -43 to 61; p = 0.74). The reduction in MVPA in the control group over the first 12-weeks was also maintained at 24-weeks (5.4 min/wk.; 95% CI = -3.6 to 4.6; p = 0.80). Secondary outcomes did not differ between groups at 24-weeks. CONCLUSIONS: Our results suggest distance-based interventions using wearable technology produce increases in MVPA that endure at least 12-weeks after the intervention is completed.

Psychological correlates of physical activity and exercise preferences in metropolitan and nonmetropolitan cancer survivors.

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

Long-term outcomes of surgical management of rectal prolapse.

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

A randomized controlled trial of WATAAP to promote physical activity in colorectal and endometrial cancer survivors.

OBJECTIVE: The objective of this study was to ascertain whether wearable technology coupled with action planning was effective in increasing physical activity (PA) in colorectal and endometrial cancer survivors at cardiovascular risk. METHODS: Sixty-eight survivors who had cardiovascular risk factors and were insufficiently active were randomized to intervention and control arms. Intervention participants were given a wearable tracker for 12 weeks, two group sessions, and a support phone call. Participants in the control arm received print materials describing PA guidelines. Assessments at baseline and 12 weeks measured triaxial and uniaxial estimates of moderate-vigorous physical activity (MVPA), sedentary behaviour, blood pressure, and body mass index (BMI). RESULTS: The intervention group significantly increased MVPA by 45 min/wk compared with a reduction of 21 min/wk in the control group. Group by time interactions were significant for minutes of MVPA (F1,126  = 5.14, P = 0.025). For those with diastolic hypertension, there was a significant group by time interaction (F1,66  = 4.89, P = 0.031) with a net reduction of 9.89 mm Hg in the intervention group. CONCLUSIONS: Significant improvements in MVPA were observed following the intervention. The results display promise for the use of pragmatic, low-intensity interventions using wearable technology.

Wearable Activity Technology And Action-Planning (WATAAP) to promote physical activity in cancer survivors: Randomised controlled trial protocol.

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

Antecedentes/Objetivo: Los sobrevivientes de cáncer tienen riesgo cardiovascular debido a la comorbilidad y al comportamiento sedentario, lo que justifica desarrollar una adecuada intervención para aumentar la práctica de actividad física. El Enfoque del Proceso de Acción de Salud (EPAS) constituye un marco teórico para el desarrollo de conductas saludables y los dispositivos electrónicos de actividad física son nuevas herramientas de automonitorización para los supervivientes de cáncer. Método: Sesenta y ocho sobrevivientes de cáncer colorrectal y ginecológico serán aleatorizados en grupos de intervención y control. Los participantes del grupo de intervención recibirán un Fitbit Alta™ para monitorizar la actividad física, sesiones grupales y aplicación de un folleto de EPAS, y una llamada telefónica de apoyo. Los participantes del grupo control únicamente recibirán un folleto basado en EPAS. Al inicio del estudio, a las 12 y 24 semanas, se evaluarán la actividad física (usando acelerómetros), la presión arterial, el Índice de Masa Corporal (IMC) y los constructos EPAS. El análisis de datos utilizará la interacción Grupo x Tiempo a partir de un análisis del Modelo Mixto Lineal General. Conclusiones: Las intervenciones de actividad física son factibles y tienen fundamentos teóricos que auguran mejorar la salud de los sobrevivientes de cáncer.

Anal squamous cell carcinoma: are we improving outcomes?

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

Wearable Activity Technology And Action-Planning (WATAAP) to promote physical activity in cancer survivors: Randomised controlled trial protocol / Pulseras inteligentes de actividad física y plan de acción (WATAAP) para promover la actividad física en sobrevivientes de cáncer: protocolo de un ensayo aleatorizado

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

ANTECEDENTES/OBJETIVO: Los sobrevivientes de cáncer tienen riesgo cardiovascular debido a la comorbilidad y al comportamiento sedentario, lo que justifica desarrollar una adecuada intervención para aumentar la práctica de actividad física. El Enfoque del Proceso de Acción de Salud (EPAS) constituye un marco teórico para el desarrollo de conductas saludables y los dispositivos electrónicos de actividad física son nuevas herramientas de automonitorización para los supervivientes de cáncer. MÉTODO: Sesenta y ocho sobrevivientes de cáncer colorrectal y ginecológico serán aleatorizados en grupos de intervención y control. Los participantes del grupo de intervención recibirán un Fitbit Alta™ para monitorizar la actividad física, sesiones grupales y aplicación de un folleto de EPAS, y una llamada telefónica de apoyo. Los participantes del grupo control únicamente recibirán un folleto basado en EPAS. Al inicio del estudio, a las 12 y 24 semanas, se evaluarán la actividad física (usando acelerómetros), la presión arterial, el Índice de Masa Corporal (IMC) y los constructos EPAS. El análisis de datos utilizará la interacción Grupo X Tiempo a partir de un análisis del Modelo Mixto Lineal General. CONCLUSIONES: Las intervenciones de actividad física son factibles y tienen fundamentos teóricos que auguran mejorar la salud de los sobrevivientes de cáncer

Outcomes in patients undergoing urgent colorectal surgery.

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

Anastomotic leaks in colorectal surgery.

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

Performing a colonoscopy 12 months after surgery for colorectal neoplasia.

BACKGROUND: There appears to be acceptance that following up patients after surgery for colorectal neoplasia is of value. However, specific issues relating to which investigations to perform and how often remain unresolved. The aim of this project was to evaluate the clinical utility of performing a colonoscopy 12 months after curative surgery for colorectal neoplasia. METHODS: Patients were selected if they had undergone a curative resection for colorectal neoplasia, and if they had had a completed colonoscopy prior to surgery. Study endpoints included: (i) compliance with follow up; (ii) the prevalence, total number, size, and histology of polyps; and (iii) identification of recurrent or metachronous cancer. RESULTS: The study group included 253 patients of mean age 69.7 years (SD 11.6) and a male : female ratio of 1.4:1.0. Colonoscopies were completed on 90% of patients at a mean of 1.1 years following surgery. A total of 149 polyps were identified in 30% of patients. On histology, 42% were tubular adenomas, 6% tubulo-villous adenomas, 7% were villous adenomas, and 37% were hyperplastic. Advanced adenomas were identified in 7.9% of patients (95% CI 4.8-12.1%). No recurrent or metachronous cancers were identified. CONCLUSION: We have observed a high prevalence of advanced adenomas in patients undergoing a 12-month, follow-up colonoscopy after curative surgery for colorectal neoplasia. The significance of these observations requires further evaluation.

Clinical utility of a de-functioning loop ileostomy.

BACKGROUND: The de-functioning loop ileostomy was introduced as a technique to create a manageable stoma that would divert the faecal stream from a more distal anastomosis in order to reduce the consequences of any anastomotic leakage. The value of de-functioning stomas is currently being challenged. The purpose of the present study was to review the clinical utility of performing a de-functioning loop ileostomy in patients undergoing colorectal surgery. METHODS: A review was undertaken of a prospective colorectal database maintained at Fremantle Hospital. All end-points were defined prior to the collection of data. The study reviewed the indications and type of surgery performed. The main end-points included (i) the prevalence and management of anastomotic leaks at the primary surgery; (ii) unplanned readmissions prior to stoma closure; and (iii) the mortality, reoperation rate, and morbidity associated with closure of the stoma. RESULTS: The study involved 233 patients of mean age 58 years (range 15-89 years) and a male:female ratio of 1.1:1. The majority of patients were undergoing elective surgery (82%) for colorectal neoplasia (71%). The commonest surgical procedure was an ultra-low anterior resection (62%). At the initial surgery, 16 patients (7.0%) developed anastomotic leaks, but only two (0.9%) required reoperation. Eleven patients (4.8%) required 12 unplanned readmissions prior to stoma closure. At closure (n = 230), there were no postoperative deaths, one patient developed an ileal anastomotic leak that was managed with antibiotics, and five patients (2.2%) required reoperation within 30 days of surgery. CONCLUSION: De-functioning loop ileostomy was found to be associated with a relatively low morbidity and no mortality.

Efficacy of transanal endoscopic microsurgery in the management of rectal polyps.

BACKGROUND AND AIM: Transanal endoscopic microsurgery (TEM) was a technique developed to allow the excision of adenomas and early-stage cancers from the rectum and distal sigmoid colon. The aim of this project was to prospectively study surgical morbidity, mortality and the local recurrence rate of all patients treated with this technique. METHODS: All patients undergoing TEM were prospectively evaluated. Endpoints to assess the surgical morbidity and mortality were defined before the study commenced. All patients underwent regular follow up to determine treatment efficacy in terms of the local recurrence rate and survival. RESULTS: The study involved 113 patients, with a mean age of 69 years (standard deviation 14 years, range 30-94 years), and a male to female ratio of 1.4:1. The mean polyp area was 20.5 cm(2) (range 1-169 cm(2)) and the mean height above the anal verge was 9.5 cm (range 4-25 cm). Histology of the tumors found 62 adenomas, 20 carcinomas in situ, and 31 adenocarcinomas. There were no unplanned returns to theater or postoperative deaths. Four patients required readmission within 30 days because of bleeding, and nine patients underwent more radical surgical procedures following histological evaluation of the resected specimens. During a mean follow up of 1.5 +/- 0.8 years (maximum 3.2 years), there have been two recurrences of villous adenomas. The actuarial local recurrence rate at 2 years is 2.4% (95% confidence interval 0.8-4.0%). CONCLUSION: TEM was demonstrated to be a safe surgical procedure, and early follow up has shown it to be an efficacious treatment for benign rectal adenomas and early rectal cancers.