BACKGROUND: In response to emergent evidence, many countries are transitioning from cytology-based to HPV screening. We evaluated the impact of an upcoming transition on health outcomes and resource utilisation in New Zealand.
METHODS: An extensively validated model of HPV transmission, vaccination, natural history and cervical screening ('Policy1-Cervix') was utilised to simulate a transition from three-yearly cytology for women 20-69 years to five-yearly HPV screening with 16/18 genotyping for women 25-69 years, accounting for population growth and the impact of HPV immunisation. Cervical cancer rates, resources use (test volumes), costs, and test positivity rates from 2015 to 2035 were estimated.
FINDINGS: By 2035, the transition to HPV screening will result in declines in cervical cancer incidence and mortality rates by 32% and 25%, respectively, compared to 2018. A potentially detectable 5% increase in cervical cancer incidence due to earlier detection is predicted for the year of transition. Annual numbers of women screened will fluctuate with the five-year screening interval. Cytology volumes will reduce by over 80% but colposcopy volumes will be similar to pre-transition rates, and program costs will be reduced by 16%. A 9% HPV test positivity rate is expected in the first round of HPV screening (2019-2023), with 2.7% of women referred for colposcopy. Transitioning from cytology to primary HPV cervical screening could avert 149 cancer cases and 45 deaths by 2035.
CONCLUSION: Primary HPV screening and vaccination will reduce cervical cancer and resources use. A small transient apparent increase of invasive cancer rates due to earlier detection may be detectable at the population level, reflecting the introduction of a more sensitive screening test. These findings can be used to inform health services planning and public communications surrounding program implementation.

Lynch syndrome is the most common hereditary form of colorectal carcinoma caused by a constitutional pathogenic mutation in a DNA mismatch repair gene. Identifying Lynch syndrome is essential to initiate intensive surveillance program for the patient and affected relatives. On behalf of the Australasian Gastrointestinal Pathology Society (AGPS), we present in this manuscript consensus guidelines for Lynch syndrome screening in patients with colorectal carcinoma. The goal of this consensus document is to provide recommendations to pathologists for diagnosis of Lynch syndrome with discussion of the benefits and limitations of each test. Universal screening for defective mismatch repair is recommended, in agreement with the recent endorsement of universal testing by the National Health and Medical Research Council in Australia and the New Zealand Ministry of Health. The value of evaluating defective mismatch repair is acknowledged not only for Lynch syndrome screening but also for therapeutic decision information in patient management. AGPS advocates appropriate government funding for the molecular tests necessary for Lynch syndrome screening (BRAF mutation, MLH1 methylation testing).

OBJECTIVES: To report the interim findings of an audit of the outcomes of sentinel node (SN) biopsy performed as a replacement for groin node dissection in women with early stage vulvar cancer in routine clinical practice in Australia and New Zealand.
METHODS: A prospective multi-center study in 8 participating centers. Eligible patients had squamous cell carcinomas clinically restricted to the vulva <4 cm in diameter. SN procedures and pathological assessment were to be performed in accordance with the methods published by the GROINSS-V collaboration [1].
RESULTS: 130 women with apparent early stage vulvar cancer were enrolled. Seventeen women subsequently did not meet the eligibility criteria and were excluded. SNs were identified in 111/113 of the remaining women. Twenty-two women had positive nodes. Sixteen of these women had at least 12 months follow up and 7 (44%) had recurrent disease. Eighty-nine women had only negative nodes. Seventy-four of these women had at least 12 months follow up and 6 (8%) had recurrent disease (including 2 [2.7%] with recurrence in the groin). On subsequent review of the two women with negative SNs who had groin recurrences, it was found that the recommended pathology protocol had not been followed. In both cases, SN metastases were identified following serial sectioning of the nodes.
CONCLUSIONS: SN biopsy is feasible in routine clinical practice. However, undetected metastases in a removed SN may be associated with groin recurrence. To ensure patient safety, strict adherence to the pathology protocol is an essential component in the utilization of the sentinel lymph node technique in vulvar cancer.

BACKGROUND: The epidemiology and implant-specific risk for breast implant-associated (BIA) anaplastic large cell lymphoma (ALCL) has been previously reported for Australia and New Zealand. The authors now present updated data and risk assessment since their last report.
METHODS: New cases in Australia and New Zealand were identified and analyzed. Updated sales data from three leading breast implant manufacturers (i.e., Mentor, Allergan, and Silimed) were secured to estimate implant-specific risk.
RESULTS: A total of 26 new cases of BIA-ALCL were diagnosed between January of 2017 and April of 2018, increasing the total number of confirmed cases in Australia and New Zealand to 81. This represents a 47 percent increase in the number of reported cases over this period. The mean age and time to development remain unchanged. The implant-specific risk has increased for Silimed polyurethane (23.4 times higher) compared with Biocell, which has remained relatively static (16.5 times higher) compared with Siltex implants.
CONCLUSIONS: The number of confirmed cases of BIA-ALCL in Australia and New Zealand continues to rise. The implant-specific risk has now changed to reflect a strong link to implant surface area/roughness as a major association with this cancer.

PURPOSE: Haematological cancers often require aggressive treatment which can cause both late and long term physical and psychosocial effects that can appear years after treatment ends. However there is a paucity of studies that focus on psychosocial issues among post-treatment haematological cancer survivors. This research aimed to explore the strategies used by haematological cancer survivors to maintain psychosocial wellbeing in the post-treatment period, and examine the barriers they identify to maintaining wellbeing.
METHOD: This research utilised a qualitative research design. Participants were recruited through the New Zealand Cancer Registry. Semi-structured interviews were conducted with 23 post-treatment haematological cancer survivors. A thematic analysis was conducted to analyse the data.
RESULTS: The analysis identified three themes describing the strategies that enabled participants to maintain psychosocial wellbeing: inner strength; support from personal connections; support from health professionals/support organisations. Two themes were also identified describing the barriers to psychosocial wellbeing: barriers to utilising personal connections; barriers to utilising support from health professionals/support organisations.
CONCLUSIONS: Psychosocial support from others was essential in maintaining wellbeing for survivors. The participants who had ready support from family and friends reported needing less psychosocial support from other sources. However, those who needed more psychosocial support did not always receive it, or know where to find it. The key barriers to this type of support were informational gaps and not having a specific contact person to ask for help. Further research is needed to support the development of interventions to reduce psychosocial distress among this underserved group of cancer survivors.

INTRODUCTION: Cancers of the skin are the most common cancers in humans, with Australia and New Zealand having the world's highest incidence. Primary prevention campaigns advise people to apply sunscreen to exposed body sites when outdoors. However, despite growing evidence that cumulative sub-erythemal exposures cause mutational damage, and trial data demonstrating benefit from daily sunscreen use, current policies do not consider the hazards of incidental (everyday) sun exposure. Thus, a Sunscreen Summit was convened to review the evidence and update the policies for people living in Australia and New Zealand.
RESULTS: After reviewing the benefits and risks of sunscreen application, the policy group concluded that people living in Australia and New Zealand should be advised to apply sunscreen to the face/head/neck and all parts of the body not covered by clothing on all days when the ultraviolet index is forecast to reach three or greater, irrespective of their anticipated activities. For planned outdoors activities, sunscreen should be used alongside other sun protection measures.
CONCLUSIONS: People living in Australia and New Zealand are now advised to apply sunscreen every day when the UV index is predicted to reach 3 or above. Implications for public health: Increased use of sunscreen as part of the daily routine to reduce incidental sun exposure will lead to decreased incidence of skin cancer in the future.

PURPOSE: Endometrial cancer accounts for 3.9% of all female cancers globally, and its incidence appears to be increasing in women under 40 years of age. This paper investigated ethnic-specific trends in endometrial cancer across different age groups in New Zealand.
METHODS: Women who were diagnosed with endometrial cancer between 1996 and 2012 were identified from the New Zealand Cancer Registry. Annual age-standardized incidence and mortality rates were calculated for each ethnicity (Māori, Pacific, and non-Māori non-Pacific) in four age groups (< 40, 40-49, 50-74, and 75 +). The estimates were adjusted for hysterectomy. Joinpoint regression analysis was used to assess trends over time and annual percentage changes (APCs) were estimated.
RESULTS: Between 1996 and 2012, age-standardized incidence rates increased in all women and significantly in the < 40, 40-49, and 50-74 age groups (APC 9.22, 3.56, and 1.65 respectively). Incidence rates were highest in Pacific women and increased most rapidly in those under 50 years of age (APC 9.36). Conversely, age-standardized mortality rates decreased in all women and significantly in the 50-74 and 75 + age groups (APC - 5.25 and - 5.06 respectively), with the highest rate observed in Pacific women.
CONCLUSION: Pacific women had the highest incidence of endometrial cancer and the trend was increasing, particularly in young women. This could be attributed, at least in part, to a high and increasing rate of obesity in these women and should be explored in future research.

INTRODUCTION: Understanding the cause of their cancer is important for many cancer patients. Childhood cancer survivors'/survivors' parents' beliefs about cancer etiology are understudied. We aimed to assess survivors'/parents' beliefs about what causes childhood cancer, compared with beliefs in the community. We also investigated the influence of clinical and socio-demographic characteristics on the participants' beliefs about cancer etiology.
METHODS: This two-stage study investigated the participants' beliefs, by using questionnaires assessing causal attributions related to childhood cancer (stage 1) and then undertaking telephone interviews (stage 2; survivors/survivors' parents only) to get an in-depth understanding of survivors'/survivors' parents beliefs. We computed multivariable regressions to identify factors associated with the most commonly endorsed attributions: bad luck/chance, environmental factors and genetics. We analyzed interviews using thematic analysis.
RESULTS: Six hundred one individuals (64.6% survivors and 35.4% survivors' parents) and 510 community comparisons (53.1% community adults, 46.9% community parents) completed the question on causal attributions. We conducted 87 in-depth interviews. Survivors/survivors' parents (73.9%) were more likely to believe that chance/bad luck caused childhood cancer than community participants (42.4%). Community participants more frequently endorsed that genetics (75.3%) and environmental factors (65.3%) played a major role in childhood cancer etiology (versus survivors' and survivors' parents: genetics 20.6%, environmental factors: 19.3%). Community participants, participants with a first language other than English, and reporting a lower quality of life were less likely to attribute bad luck as a cause of childhood cancer. Community participants, all participants with a higher income and higher education were more likely to attribute childhood cancer etiology to environmental factors.
CONCLUSION: Causal attributions differed between survivors/survivors' parents and community participants. Most of the parents and survivors seem to understand that there is nothing they have done to cause the cancer. Understanding survivors' and survivors' parents' causal attributions may be crucial to address misconceptions, offer access to services and to adapt current and future health behaviors.

BACKGROUND: Human papillomavirus (HPV) is a common sexually transmitted infection that is implicated in 99.7% of cervical cancers and several other cancers that affect both men and women. Despite the role that HPV plays in an estimated 5% of all cancers and the evolving role of HPV vaccination and testing in protecting the public against these cancers, preliminary research in New Zealand health professionals suggest knowledge about HPV may not be sufficient.
METHODS: A total of 230 practice nurses, smear takers and other clinical and laboratory staff who attended a range of training events completed a cross-sectional survey between April 2016 and July 2017. The survey explored four broad areas: demographics and level of experience, HPV knowledge (general HPV knowledge, HPV triage and test of cure (TOC) knowledge and HPV vaccine knowledge), attitudes towards the HPV vaccine and self-perceived adequacy of HPV knowledge.
RESULTS: The mean score on the general HPV knowledge questions was 13.2 out of 15, with only 25.2% of respondents scoring 100%. In response to an additional question, 12.7% thought (or were unsure) that HPV causes HIV/AIDS. The mean score on the HPV Triage and TOC knowledge questions was 7.4 out of 10, with only 9.1% scoring 100%. The mean score on the HPV vaccine knowledge questions was 6.0 out of 7 and 44.3% scored 100%. Only 63.7% of respondents agreed or strongly agreed that they were adequately informed about HPV, although 73.3% agreed or strongly agreed that they could confidently answer HPV-related questions asked by patients. Multivariate analyses revealed that knowledge in each domain predicted confidence in responding to patient questions. Furthermore, the number of years since training predicted both HPV knowledge and Triage and TOC knowledge.
DISCUSSION: Although overall level of knowledge was adequate, there were significant gaps in knowledge, particularly about the role of HPV testing in the New Zealand National Cervical Screening Programme. More education is required to ensure that misinformation and stigma do not inadvertently result from interactions between health professionals and the public.

In New Zealand, oncoplastic surgery is common, but partial breast reconstruction presents challenges for radiation therapy targeting. Tissue rearrangement creates ambiguity when targeting the tumor bed, with resultant overestimation of treatment volumes. Thus, adoption of advanced methods of radiation therapy have been hindered. This pilot study describes use of a novel three-dimensional implant that provides a scaffolding for tissue ingrowth during partial breast reconstruction and delineates the tumor bed more precisely to assist radiation planning and mammographic surveillance. After informed consent, 15 women were implanted with the three-dimensional bioabsorbable implant. The device was sutured to the tumor bed during lumpectomy, and tissue flaps were mobilized and attached to the implant. Visualization of the marker and radiation treatment volumes were recorded and compared. The implant provided volume replacement and helped to maintain breast contour. Cosmetic outcomes were excellent; no device- or radiation-related complications occurred. One patient had a postoperative hematoma that resolved after percutaneous drainage; there were no postoperative infections. Three-year follow-up shows no tumor recurrences and no untoward effects. When compared to conventional radiation targeting, use of the implant showed that a greater than 50 percent reduction in treatment volume was possible in some cases. Three-year mammograms show no significant artifact, normal tissue ingrowth, and minimal fibrosis. This study describes a method of oncoplastic breast reconstruction using an implantable device that marks the site of tumor excision and provides for volume replacement with tissue ingrowth. Patients tolerated it well, and radiation therapy planning, positioning, and treatment were facilitated.

INTRODUCTION: This study aims to examine the impact of radiotherapy on the cardiovascular health of women diagnosed with breast cancer in the Waikato region in New Zealand.
METHODS: Women diagnosed with stage 0-III breast cancer and recorded in the Waikato Breast Cancer Registry were divided into two groups: a radiotherapy group and a no-radiotherapy group. Baseline characteristics and treatments were compared in the two groups. Kaplan-Meier survival analysis was performed to compare cardiovascular morbidity and mortality. Cox Proportional Hazard regression analysis was used to estimate the hazard ratio of radiotherapy on the risk of cardiovascular morbidity and mortality while adjusting for other factors.
RESULTS: A total of 3528 women were included in this study, with 2303 in the radiotherapy group and 1225 in the no-radiotherapy group. At 10-year follow-up, 11.7% of women in the radiotherapy group and 19.4% in the no-radiotherapy group experienced cardiovascular events. Only 2.3% of patients who received radiotherapy died of cardiovascular disease by 10 years compared to 7.0% in the no-radiotherapy group. After adjusting for clinically significant factors, there was unexplained reduced risk of developing cardiovascular disease in the radiotherapy group compared to the no-radiotherapy group (HR 0.73, 95% CI: 0.59-0.92). No significant difference was found in cardiovascular mortality between the two groups.
CONCLUSIONS: Radiotherapy appears less likely to be offered to patients at higher risk of cardiovascular disease. No evidence of increased risk of a cardiovascular event was found in the group of women with breast cancer treated with radiotherapy and current regimens appear safe. Traditional cardiovascular risk factors remain the main culprits in this setting. Clinicians should work with patients in managing these risk factors for optimal results.

BACKGROUND: Non-melanoma skin cancer (NMSC) is the most commonly diagnosed and costly cancer in Australasia. Cutaneous squamous cell carcinoma (cSCC) accounts for approximately 25% of NMSC. A better understanding of predictors of close and positive margins following surgical excision will help guide treatment.
METHODS: A retrospective study was carried out of all primary cSCC histologically diagnosed in Northland, New Zealand in 2015. The cohort was identified by searching the regional pathology database. The primary outcome of interest was positive and close (≤1mm) margin rate following surgical excision and factors influencing them. Secondary outcomes of interest were outcomes of re-excisions.
RESULTS: A total of 1,040 cSCC were identified in 890 unique patients and 825 lesions were surgically excised. Increased odds of positive margin on surgical excision was found with increased tumour thickness (OR 1.56, 95% CI 1.24-1.96), tumours from the head and neck (OR 2.78, 95% CI 1.33-5.80) and those excised in primary care (OR 2.20, 95% CI 1.07-4.52). Increased odds of close margins was found in females (OR 2.01, 95% CI 1.3-3.2) and excision in primary care (OR 2.44 95% CI 1.5-3.98). Residual tumour was present in 13 (31.7%) patients with positive margins and 0 patients with close margins.
CONCLUSIONS: Lesions of the head and neck, those removed in primary care and with increased tumour thickness were more likely to have positive margins following surgical excision. Close margins were associated with excision in primary care and female gender. The value of re-excising tumours with close margins remains uncertain.

BACKGROUND: Prolonged postoperative ileus is a common major complication after abdominal surgery. Retrospective data suggest that ileus doubles the cost of inpatient stay. However, current economic impact data are based on retrospective studies that rely on clinical coding to diagnose ileus.
OBJECTIVE: The aim of this study was to determine the economic burden of ileus for patients undergoing elective colorectal surgery.
DESIGN: Economic data were audited from a prospective database of patients who underwent surgery at Auckland City Hospital between September 2012 and June 2014.
SETTINGS: Auckland City Hospital is a large tertiary referral center, using an enhanced recovery after surgery protocol.
PATIENTS: Patients were prospectively diagnosed with prolonged postoperative ileus using a standardized definition.
MAIN OUTCOME MEASURES: The cost of inpatient stay was analyzed with regard to patient demographics and operative and postoperative factors. A multivariate analysis was performed to determine the cost of ileus when accounting for other significant covariates.
RESULTS: Economic data were attained from 325 patients, and 88 patients (27%) developed ileus. The median inpatient cost (New Zealand dollars) for patients with prolonged ileus, including complication rates and length of stay, was $27,981 (interquartile range= $20,198 to $42,174) compared with $16,317 (interquartile range = $10,620 to $23,722) for other patients, a 71% increase in cost (p < 0.005). Ileus increased all associated healthcare costs, including medical/nursing care, radiology, medication, laboratory costs, and allied health (p < 0.05). Multivariate analysis showed that ileus remained a significant financial burden (p < 0.005) when considering rates of major complications and length of stay.
LIMITATIONS: This is a single-institution study, which may impact the generalizability of our results.
CONCLUSIONS: Prolonged ileus causes a substantial financial burden on the healthcare system, in addition to greater complication rates and length of stay in these patients. This is the first study to assess the financial impact of prolonged ileus, diagnosed prospectively using a standardized definition. See Video Abstract at http://links.lww.com/DCR/A825.

AIM: Earlier diagnosis of hepatitis B virus (HBV) related hepatocellular carcinoma (HCC) increases treatment options and survival. The aim of this study is to evaluate which factors are associated with late presentation of HBV-related HCC.
METHOD: This is a retrospective review of all cases of HBV-related HCC diagnosed with late-stage/incurable HCC in New Zealand between 2003 and 2017. Cases were defined as patients with a positive hepatitis B surface antigen (HBsAg), and advanced (not amenable to potentially curable treatments) HCC at initial diagnosis. Patients were categorised into four groups according to potential reasons for late presentation: no previous diagnosis of HBV infection (Group A); known HBV diagnosis but not receiving HCC surveillance (Group B); known HBV diagnosis and receiving suboptimal HCC surveillance (Group C); and known HBV diagnosis and receiving optimised HCC surveillance (Group D).
RESULTS: A total of 368 patients were reviewed. The average age at death was 59 years, and the majority of patients were Māori (39%), Pacific (34%) or Asian (20%). The incidence of patients presenting with HBV-related advanced HCC increased from 4.5 cases to 6.3 cases per million people over the review period. Of the cases, 40% were categorised into Group A, 26% into Group B, 12% into Group C and 23% in Group D. Overall, the median survival was 138 days, and this did not change during the study period. Patients receiving optimised surveillance (Group D) survived longer (mean 469 days) than patients in Group A (90 days), Group B (145 days) or Group C (152 days) (p<0.05). Patients in Group D were more likely to be treated with transarterial chemoembolisation than patients in other groups (40% vs 15%, p<0.05).
CONCLUSION: This study has highlighted the need for improved rates of HBV diagnosis, better follow-up of those infected and the importance of optimal HCC surveillance. In New Zealand, HBV-related HCC disproportionately affects minority ethnic groups, and given the increasing incidence, provides a potential domain to reduce health inequities.

Fucoidan, a sulfated polysaccharide extracted from brown seaweeds, has been shown to possess various antioxidant, anticoagulant, antiviral, and anticancer functions. In this study, we focused on low molecular weight fucoidan (LMWF) which was extracted from New Zealand

INTRODUCTION: To report a series of patients with osteoid osteoma treated by radiofrequency ablation in whom no complications or recurrences occurred.
METHODS: Over a 13-year period, 32 consecutive patients with osteoid osteoma were treated by radiofrequency ablation in an Australasian teaching centre.
RESULTS: All patients had resolution of symptoms with no complication or recurrence.
CONCLUSIONS: This series is further evidence for the use of radiofrequency ablation as the primary treatment for osteoid osteoma.

In 2008, a quadrivalent human papillomavirus (HPV) vaccine (genotypes 6, 11, 16, 18) became available in New Zealand. This study investigated whether the proportion of cervical intraepithelial neoplasia grade 2 (CIN2) lesions associated with HPV genotypes 16 and 18 changed over time in young women recruited to a prospective CIN2 observational management trial (PRINCess) between 2013 and 2016. Partial HPV genotyping (16, 18, or other high risk HPV) was undertaken on n = 392 women under 25 years (mean age 21.8, range 17-24) with biopsy-diagnosed CIN2. High risk HPV genotypes were detected in 96% of women with CIN2 lesions. Between 2013 and 2016, the proportion of women whose liquid-based cytology samples were HPV 16 or 18 positive decreased from 43% to 13%. HPV vaccination status was known for 78% of women. Between 2013 and 2016, the proportion of HPV 16/18 positivity did not significantly change in HPV-vaccinated women, but decreased from 66% to 17% in unvaccinated women. The reducing proportion of HPV 16/18-related CIN2 in our cohort of young New Zealand women may be attributable to the introduction of a national HPV vaccination program. The substantial decrease in HPV 16/18 positivity observed in unvaccinated women is likely to be due to a herd effect.

BACKGROUND: The association between body mass index (BMI) and risk of breast cancer depends on time of life, but it is unknown whether this association depends on a woman's familial risk.
METHODS: We conducted a prospective study of a cohort enriched for familial risk consisting of 16,035 women from 6701 families in the Breast Cancer Family Registry and the Kathleen Cunningham Foundation Consortium for Research into Familial Breast Cancer followed for up to 20 years (mean 10.5 years). There were 896 incident breast cancers (mean age at diagnosis 55.7 years). We used Cox regression to model BMI risk associations as a function of menopausal status, age, and underlying familial risk based on pedigree data using the Breast and Ovarian Analysis of Disease Incidence and Carrier Estimation Algorithm (BOADICEA), all measured at baseline.
RESULTS: The strength and direction of the BMI risk association depended on baseline menopausal status (P < 0.001); after adjusting for menopausal status, the association did not depend on age at baseline (P = 0.6). In terms of absolute risk, the negative association with BMI for premenopausal women has a much smaller influence than the positive association with BMI for postmenopausal women. Women at higher familial risk have a much larger difference in absolute risk depending on their BMI than women at lower familial risk.
CONCLUSIONS: The greater a woman's familial risk, the greater the influence of BMI on her absolute postmenopausal breast cancer risk. Given that age-adjusted BMI is correlated across adulthood, maintaining a healthy weight throughout adult life is particularly important for women with a family history of breast cancer.

A case of nasal myiasis that occurred in February 2017 in the Northland region was the first involving L. cuprina naturally-acquired in New Zealand.

AIMS: To understand colorectal cancer (CRC) symptoms experienced by Aotearoa/New Zealand patients and to describe patient-experienced pathways and factors which may be associated with delayed diagnosis.
METHODS: Ninety-eight patients diagnosed with CRC, recruited via a national charity, completed a questionnaire. Questions included demographics, symptoms, help-seeking and diagnostic pathways followed.
RESULTS: Of 98 participants, 72 (73%) were aged under 60 years; most were symptomatic (n=93, 95%) and first discussed symptoms with someone who was not a healthcare professional (HCP) (n=71, 79%). The first HCP approached was usually a general practitioner (n=81, 83%). Symptom-to-diagnosis interval (SDI) was often six months or more (n=52, 56%) among our younger cohort. Delay was more likely if patients were younger (P=0.05), without a tertiary qualification (P=0.03), reported a poor/neutral experience at their first related HCP appointment (P=0.02), or were diagnosed in the public sector (P=0.01).
CONCLUSIONS: Few patients initially suspected bowel cancer or reported embarrassment seeking care; those who did were most likely to experience changes in bowel habit or bleeding. Our study is small, and not representative of all those diagnosed with CRC in New Zealand; yet it provides important first insights into patients' diagnostic experiences.

BACKGROUND: Epidermal Growth Factor Receptor (EGFR) mutation testing is recommended for patients with non-squamous non-small cell lung cancer (NSCLC) but not all eligible patients get tested, which may bias the mutation prevalence estimated. This study aims to examine trends in the uptake of EGFR mutation testing in patients with non-squamous NSCLC in New Zealand; to develop a composite metric that quantifies the influences of demographic and clinico-pathological factors on the testing uptake; and to estimate the prevalence of EGFR mutation if all patients were tested.
METHODS: This population-based study involved all patients who were diagnosed with non-squamous NSCLC in four health regions in New Zealand between January 2010 and December 2015. Eligible patients were identified from the New Zealand Cancer Registry and information on EGFR mutation testing was obtained through linkage to TestSafe, a clinical information sharing service, and laboratory records.
RESULTS: Of 2701 eligible patients, 1059 (39.2%) were tested for EGFR mutation. The testing prevalence increased (3.7% in 2010 to 64.6% in 2014) and the influences of demographic and clinic-pathological factors decreased from 2010 to June 2014, and remained stable afterward. Of the tested patients, 229 (21.6%) were mutation positive with a decreasing trend observed from 2010 (43.8%) to June 2014 (16.8%). The best-fit log-linear model estimated the prevalence of EGFR mutation, if all patients were tested, as 15.5% (95% CI: 13.2%-18.0%).
CONCLUSION: The methods described here allowed a more accurate estimation of the prevalence of EGFR mutation.

Adequate coverage of sites harbouring potential microscopic disease is paramount, where the clinical decision has been made to include regional lymph node radiotherapy for patients with breast cancer. This must be achieved in balance with minimising dose to normal tissues. Several international consensus guidelines detailing clinical target volumes (CTVs) are available, but there is currently no agreement as to which is most appropriate for a given clinical situation. Contouring guidelines are beneficial for routine practice and essential for clinical trial quality assurance. The aims of this study were as follows: to provide a single point of comparison of four commonly used contouring guidelines, including one used in a current Trans-Tasman Radiation Oncology Group trial; and to undertake a systematic review of existing studies which map sites of breast cancer recurrence against contouring guidelines. Two international consensus guidelines (European Society for Radiotherapy and Oncology, and Radiation Therapy Oncology Group) were compared with two clinical trial guidelines (TROG 12.02 PET LABRADOR and the Proton/Photon trial NCT02603341 RADCOMP). Comprehensive literature search for patterns of failure studies was undertaken using Embase and Pubmed. We detail the small but significant differences between the breast consensus guidelines, particularly the supraclavicular (SCF) and internal mammary chain CTVs. Seven series were found mapping recurrence patterns. These results are discussed in the context of the contouring guidelines. Several studies found the SCF CTV is the area at greatest risk of geographical 'miss'. This review will facilitate further discussion about guideline selection and modification, particularly for future clinical trials in Australia and New Zealand.

AIM: The incidence of melanoma in situ varies throughout the world. It is associated with excellent outcomes, however many of those untreated will go on to develop invasive melanoma with a worse prognosis. There is no previously published data on melanoma in situ (MIS) in New Zealand. Further information is needed to enable better understanding of the disease spectrum.
METHODS: De-identified data were obtained from the New Zealand Cancer Registry (NZCR) by way of computerised search for MIS diagnosis. A separate search was performed to identify all patients with invasive melanoma. World Health Organization standard population was used for calculating age standardised rates.
RESULTS: There was a trend to increasing cases of MIS, but a relative plateauing of invasive melanoma. The number of cases for MIS overtook invasive melanoma in 2012. Overall, men had a significantly higher incidence compared to women. Incidence rates varied markedly between different regions of the country.
CONCLUSIONS: This paper provides new information about the epidemiology of MIS in New Zealand and its relevance to clinical practice. Public education strategies may be beginning to show effect with the goal of increasing prevention and earlier detection and treatment to enable decrease in melanoma mortality.

AIM: The aim of this study was to examine a potential ethnic disparity in the phenotype of polycythaemia vera (PV) between New Zealand European and Polynesian patients.
METHOD: A retrospective review of medical records was conducted at Middlemore Hospital to identify adult patients with PV diagnosed between 1987 and 2007. Data extracted included diagnostic criteria, ethnicity, age, complications and survival.
RESULTS: Eighty-eight adult patients with PV were identified during 1987-2007, 49 (55.7%) were Europeans and 36 (40.9%) Polynesians. The most striking finding was that Polynesian patients presented almost 14 years younger than Europeans (mean age of 54 years versus [vs] 68, respectively; P<.001). The white cell and platelet counts were higher in Polynesians compared with Europeans (mean white cell count of 22x109/L vs 13x109/L; mean platelet count of 648x109/L vs 512x109/L, respectively; P<.05 for both). The rate of JAK2 V617F mutation in Polynesians was 96%, equivalent to other large cohorts of European patients. The rates of long-term complications were comparable between Polynesians and Europeans, but the predicted impact on life expectancy was more severe for Polynesians.
CONCLUSION: New Zealand Polynesian patients present with a distinctive PV phenotype. Their younger age at presentation suggests a different risk factor profile or a higher genetic susceptibility. We hope our observations initiate larger epidemiological and genetic studies to help elucidate the cause.

BACKGROUND: Cervical cancer rates are over twice as high, and screening coverage is lower, in Māori women compared to other women in New Zealand, whereas uptake of HPV vaccine is higher in Maori females. We aimed to assess the impact of HPV vaccination and the proposed transition to 5-yearly primary HPV screening in Māori and other women in New Zealand, at current participation levels; and additionally to investigate which improvements to participation in Māori females (in vaccination, screening, or surveillance for screening-defined higher-risk women) would have the greatest impact on cervical cancer incidence/mortality.
METHODS: An established model of HPV vaccination and cervical screening in New Zealand was adapted to fit observed ethnicity-specific data. Ethnicity-specific models were used to estimate the long-term impact of vaccination and screening (vaccination coverage 63% vs 47%; five-year screening coverage 68% vs 81% in Maori vs European/Other women, respectively).
RESULTS: Shifting from cytology to HPV-based screening is predicted to reduce cervical cancer incidence by 17% (14%) in Maori (European/Other) women, respectively. The corresponding reductions due to vaccination and HPV-based screening combined were 58% (44%), but at current participation levels long-term incidence would remain almost twice as high in Māori women (6.1/100,000 compared to 3.1/100,00 in European/Other women). Among strategies we examined, the greatest impact came from high vaccine coverage and achieving higher attendance by Māori women under surveillance for screen-detected abnormalities.
CONCLUSION: Relative reductions in cervical cancer due to vaccination and HPV-based screening are predicted to be greater in Maori than in European/Other women. While these interventions have the potential to substantially reduce between-group differences, cervical cancer incidence would remain higher in Maori women. These findings highlight the importance of multiple approaches and the potential influence of factors beyond HPV prevention.

BACKGROUND: The only available predictive models for the outcome of breast cancer patients in New Zealand (NZ) are based on data in other countries. We aimed to develop and validate a predictive model using NZ data for this population, and compare its performance to a widely used overseas model, the Nottingham Prognostic Index (NPI).
METHODS: We developed a model to predict 10-year breast cancer-specific survival, using data collected prospectively in the largest population-based regional breast cancer registry in NZ (Auckland, 9182 patients), and assessed its performance in this data set (internal validation) and in an independent NZ population-based series of 2625 patients in Waikato (external validation). The data included all women with primary invasive breast cancer diagnosed from 1 June 2000 to 30 June 2014, with follow up to death or Dec 31, 2014. We used multivariate Cox proportional hazards regression to assess predictors and to calculate predicted 10-year breast cancer mortality, and therefore survival, probability for each patient. We assessed observed survival by the Kaplan Meier method. We assessed discrimination by the C statistic, and calibration by comparing predicted and observed survival rates for patients in 10 groups ordered by predicted 10-year survival. We compared this NZ model with the Nottingham Prognostic Index (NPI) in this validation data set.
RESULTS: Discrimination was good: C statistics were 0.84 for internal validity and 0.83 for an independent external validity. For calibration, for both internal and external validity the predicted 10-year survival probabilities in all groups of patients, ordered by predicted survival, were within the 95% confidence intervals (CI) of the observed Kaplan-Meier survival probabilities. The NZ model showed good discrimination even within the prognostic groups defined by the NPI.
CONCLUSIONS: These results for the New Zealand model show good internal and external validity, transportability, and potential clinical value of the model, and its clear superiority over the NPI. Further research is needed to assess other potential predictors, to assess the model's performance in specific subgroups of patients, and to compare it to other models, which have been developed in other countries and have not yet been tested in NZ.

BACKGROUND: Precision medicine aims to link molecular targets in tumours with corresponding therapies, particularly for patients with rare cancers. Innovative approaches are needed to translate molecular opportunities into clinical care. The Cancer Molecular Screening and Therapeutics (MoST) program employs a molecular screening platform to identify molecular changes of therapeutic relevance (actionable changes) and a master protocol for multiple, parallel signal-seeking clinical substudies, focused on therapies for patients with rare and neglected cancers. Methods and analysis: Archival pathology laboratory samples from patients with treatment-refractory advanced solid cancer of any histologic type undergo molecular tumour profiling. Following review by a Molecular Tumour Board, eligible patients are offered treatment in therapeutic substudies. This novel master protocol allows expedited addition of individual substudies; at least 12 open label, single arm, signal-seeking substudies during the initial 4 years of MoST are planned. The primary objectives are to identify signals of efficacy for developing biomarker-driven therapies and biomarkers that more accurately predict response to therapy, as well as to evaluate the MoST design. Ethics approval: The program has been approved by the St Vincent's Hospital Sydney Human Research Ethics Committee (reference, HREC/16/SVH/23). Dissemination of results: A report summarising and interpreting collected study data will be published. Our findings will be presented at national and international conferences and scientific meetings, and published in peer-reviewed journals.
TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry: ACTRN12616000908437 (8 July 2016).

Transoral robotic surgery (TORS) provides improved access to head and neck subsites resulting in well-validated functional and oncological outcomes, but access to and cost of robotic platforms can limit their use. Evidence suggests TORS is increasingly being adopted globally, but there is a paucity of data on the adoption and diffusion of TORS in Australia and New Zealand. A cross-sectional analysis was performed. An online survey was distributed to otolaryngologists and head and neck surgeons through three different Australian and New Zealand specialty membership databases. A 5-point Likert scale based on a Unified Theory of Acceptance and Use of Technology (UTAUT) model was incorporated to assess barriers and facilitators to adoption. 77 respondents completed the survey. 43.6% of head and neck surgeons had performed TORS. The most common cases were lateral oropharyngectomy (35.9%), base of tongue resection (33.3%), tongue base mucosectomy (28.2%), supraglottic laryngectomy (15.4%) and TORS for obstructive sleep apnoea (12.8%). Perceived barriers to adoption were high costs, access to and availability of the robotic platform and limited training opportunities. This study provides evidence of adoption of TORS in Australia and New Zealand; however, there is a perception that significant barriers to adoption persist. Results from this study may help guide decisions on how we train and license surgeons in the era of this technology.

AIM: The quality of rectal cancer management within New Zealand provincial hospitals is largely unknown. This study was conducted to appraise and benchmark the management of rectal cancer in provincial New Zealand centres as compared to specialist tertiary centres.
METHOD: Retrospective data was collected for all patients who underwent elective rectal cancer resection in six provincial New Zealand hospitals from January 2012 to December 2013. This was then compared with data from two tertiary hospitals over the same time period. The complete management pathway was evaluated.
RESULTS: A total of 124 provincial and 145 tertiary rectal cancer resections were analysed. Completeness of preoperative staging was comparable between provincial and tertiary centres, as was type of surgical procedure performed and rates of clear surgical margins. A statistically significant difference was observed in mean number of lymph nodes analysed (10.3 v 17.2), reporting of mesorectal grade (61% v 77%), and completion colonoscopy rates (91% v 99%), all of which were lower in provincial hospitals. Multidisciplinary team discussion, rates of neoadjuvant therapy and post-operative parameters such as 30-day mortality (0.8% v 1.4%), length of stay (11.9 v 12.4 days), anastomotic leak (7% v 5%) and return to theatre (8% v 8%), were similar.
CONCLUSION: Management of rectal cancer in provincial hospitals is comparable to specialist centres, however lymph node harvest, reporting of mesorectal grade and complete colonoscopy were factors identified which were lower in the provincial group. Provincial rectal cancer management remains an important resource for patients living outside major centres.

BACKGROUND: Radial-probe endobronchial ultrasound (radial-EBUS) is becoming an important investigation for peripheral pulmonary lesions (PPL). A key advantage of radial-EBUS is the favourable risk profile compared with current gold-standard computerised tomography-guided biopsy.
AIM: To investigate the diagnostic yield, predictors of positive yield and radial-EBUS safety in a New Zealand institution. We also determined whether molecular analysis was possible on the same tissue samples.
METHODS: We performed a retrospective analysis of all patients (n = 68) from Middlemore Hospital, Auckland, undergoing radial-EBUS with guide-sheath for PPL from March 2015 to August 2016. Clinical, radiological and procedural data were collected. Radial-EBUS diagnostic yield was determined for malignant and benign diagnoses, and molecular analysis yield was determined on appropriate malignant samples. Logistic regression was used to determine factors predicting successful radial-EBUS.
RESULTS: Overall diagnostic yield of radial-EBUS was 55.9% (95% confidence interval (CI): 44.3-67.9). Malignant diagnostic sensitivity was 60.8% (95% CI: 46.1-74.2) and benign diagnostic sensitivity was 50% (95% CI: 23-77). Lesions close to the hilum (P = 0.039), concentric radial-probe positioning (P = 0.008) and the use of forceps as first instrument (P = 0.0049) significantly predicted successful diagnostic yield. Of the malignant cases 81.0% (95% CI: 58.1-94.6) were sufficient for molecular analysis. Pneumothorax occurred in 4.4% (95% CI: 0.9-12.4), none required chest drain intervention. There were no cases of significant pulmonary haemorrhage.
CONCLUSION: Radial-EBUS was shown to be safe with diagnostic yield similar to international reports. Important predictors of success include distance from hilum, probe position and forceps as first instrument. We also demonstrated that molecular analysis is possible in radial-EBUS obtained samples.