Colorectal and Peritoneal Oncology Annual Service Report 2021 - 2022

Service Report 2022 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust

Highly Specialised Service (HSS) Colorectal and Peritoneal Oncology Centre (CPOC) The Christie NHS Foundation Trust

June 2022

The Christie NHS Foundation Trust Wilmslow Road

Withington Manchester M20 4BX

http://www.christie.nhs.uk/cpoc

Service Report 2022 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust

CONTENTS

1

INTRODUCTION

3

2

WORKFORCE/INFRASTRUCTURE DEVELOPMENT

4

3

PATIENT AND PUBLIC ENGAGEMENT 3.1 Patient Day

6 7 9 9

3.2 3.3 3.4 3.5 3.6 3.7 3.8 3.9

Nurse led surveillance telephone follow up

Nurse led teaching

ePROMS

Complaints Compliments

11 11 12 12 13 13 14 15 15 15 15 16 18 18 19 21 22 24 25 27 28 29 29 30 31 32

Website & Social Media

Accommodation

Fundraising

3.10 Awards for Patient Care

4

EDUCATION AND TRAINING 4.1 Fellowships

4.2 4.3 5.4 5.5

RanD Academy

CRS/HIPEC for Ovarian Cancer

Education & Courses Academic Meetings

5

RESEARCH 5.1

Biomarker research Teaching & Innovation

5.2 5.3 5.4 5.5 5.6 5.7

Clinical Outcomes & Treatment Effects

Conferences and Meetings

Grants

Publications

Book Chapters

6

UNIT DATA 6.1

Referrals

6.2 6.3 6.4 6.5 6.6 6.7 6.8

Demographics

Assessment and treatment

Specialist commissioning (appendix) assessment/follow up activity

Quality

Completeness of Cytoreduction scores

Complications

Survival

7.

APPENDIX I: PROCEDURE ACTIVITY

34

8.

APPENDIX II: PCI AND CC SCORES BY DISEASE GROUP

36

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Service Report 2022 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust

1.

INTRODUCTION

The Christie Colorectal and Peritoneal Oncology Centre (CPOC) Peritoneal Tumour Service (PTS) has experienced a 44% increase in appendiceal tumour activity with annual referrals rising from 259 patients in 20/21 to 373 patients in 21/22. We have also seen a 12.6% increase in colorectal peritoneal metastases (CRPM) referrals rising from 198 patients in 20/21 to 223 patients in 21/22, making this the busiest year for referrals in our 20-year history. In 21/22 we undertook 195 PTS procedures (compared to 188 in 20/21), also our highest annual number to date. 122 procedures were performed in appendiceal and 73 in CRPM patients. Other CPOC activity not mentioned in this report includes (i) Supporting other trusts in Greater Manchester with their primary colorectal cancer workload through converting from a ‘ Covid Green ’ to a ‘ Cancer Hub ’ site offering an additional operating list a week; (ii) Anal cancer centre; (iii) Centre for advanced & recurrent pelvic tumours including exenteration and sacrectomy; (iv) Regional retroperitoneal sarcoma service; and (v) Neuroendocrine tumours. We have supported our gynaecologists in 14 cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) procedures for ovarian cancer. Our outcomes indicate a high-quality service. For all patients undergoing CRS and HIPEC in 21/22, we achieved a complete (CC0/1) cytoreduction in 74%. In the 195 patients we operated on over the past year, we had a minor complication rate of 33.30%, a major complication rate of 9.20%, with a 1% 90-day mortality rate (2 patients). This was not significantly different to our overall minor complication rate of 25.9%, major complication rate of 13.2%, and 90-day mortality of 0.59% in 1,694 cases since 2011. Our 5-year overall survival in patients with low grade appendiceal mucinous neoplasms, malignant appendiceal tumours and colorectal peritoneal metastases of 86%, 64% and 37% respectively at 72 months’ post treatment. These results compare favourably to internationally published data. As a result of the Covid 19 pandemic, we kept biosecurity measures in place in 21/22 including wearing PPE in clinical areas, weekly PCR staff testing, restricting visitors, and offering remote consultations (video and telephone) where possible. Patients undergoing major surgery were swabbed within 5 days of the procedure and again on days 3 and 7 post-operatively, with most admitted on the day of surgery. We have not needed to close our main ward on a single occasion in the past year. We continue to be a hub for training hosting 2 ACPGBI/RCS advanced colorectal malignancy fellows, 5 European Society of Peritoneal Surface Oncology fellows, 1 NIHR Academic Clinical Lecturer, 1 European Society of Medical Oncology fellow, 1 Postgraduate Institute of Medicine Sri-Lankan fellow, and 1 International Fellow in Surgical Oncology from the National Board of Examiners in India. Our peritoneal research portfolio has grown with over £5m in active grants from CRUK, MRC, and NIHR. We have been supported by The Christie charity and Pseudomyxoma Survivor charity has made a significant contribution to our patients’ and their families experience.

Mr. Omer Aziz Lead Clinician The Christie CPOC PTS June 2022

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Service Report 2022 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust

2. WORKFORCE

Name

Job Title

Mr O Aziz

Consultant Surgeon/ Lead Clinician PTS service Consultant Surgeon/ Lead Clinician Colorectal service Consultant Surgeon/ Associate Medical Director

Mr H Clouston Mr CR Selvasekar Mr MS Wilson Prof ST O’Dwyer Prof AG Renehan

Consultant Surgeon Consultant Surgeon

Professor of Cancer Studies and Surgery, Honorary Consultant

Mr J Wild Ms R Fish

Consultant Surgeon/ Lead for Endoscopy

Consultant Surgeon Consultant Surgeon

Mr P Sutton

Mr R Deshpande Prof MP Saunders Dr S Mullamitha

Consultant Hepatobiliary Surgeon

Consultant Oncologist Consultant Oncologist Consultant Oncologist Consultant Oncologist

Dr M Braun Dr J Barriuso Dr R Kochhar Dr D Mullan

Lead Consultant Radiologist

Consultant Radiologist

Dr V Kasipandian Dr B Chakrabarty

Lead Consultant Anaesthetist/ Inpatient Clinical Lead

Lead Consultant Histopathologist Lead Clinical Nurse Specialist

R Halstead L Wardlow R Connolly

Clinical Nurse Specialist Clinical Nurse Specialist Clinical Nurse Specialist

A Coop F Akhtar

Clinical Nurse Specialist secretary

S Madden A Colclough P Kennedy

HIPEC Service Manager

HIPEC Practitioner HIPEC Practitioner HIPEC Practitioner Service Manager

R Wood S Wroe

P Diez Echave

Data Manager

H Marley G Harrison B Tyrrell A White G Barrett

Administration Support Manager

Medical Secretary Medical Secretary Medical Secretary Medical Secretary Medical Secretary Medical Secretary Research Associate

M Cunningham M McKenna L Malcomson

M Ahmed R Nagaraju

CPOC Research Manager

CPOC Lab Manager

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Service Report 2022 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust

Consultant Surgeons

In 21/22 CPOC maintained a consultant workforce of 8.5 WTE PTS consultant surgeons. In addition to their PTS commitments, our consultants are also core members of the anal cancer, advanced pelvic surgery, retroperitoneal sarcoma, neuroendocrine, and gynaecological MDTs.

Clinical Nurse Specialists (CNS)

This team of 4 has remained stable over the past 12 months. The appointment of Faizah Akhtar as their dedicated secretary/admin support has been a success, helping them to concentrate more on seeing, speaking to, and supporting our patients

Admin/Secretarial service

Paul Diez Echave has settled into his role as our Data Manager in 2020. We had a full complement of medical secretaries in 21/22 however anticipate changes in personnel over the next year with planned retirement and new members due to join the team.

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Service Report 2022 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust

HIPEC Practitioners

Ms Sarah Madden, our HIPEC service manager and her team of 3 HIPEC practitioners (Andy Colclough, Pam Kennedy and R Wood) saw us transition from an open to a closed HIPEC technique in the pandemic. A new practitioner (Sue Mlambo) has just been appointed. All our HIPEC practitioners are UK Oncology Nursing Society SACT trained and have obtained the academic training to receive their competency passport. This is revalidated annually.

Managerial staff

Dr Neil Bayman is our new medical director. Ms Vicky Sharples had joined us as Deputy Chief Operating Officer/Divisional Director of CSSS. Ms Mary Starr has remained or Surgery Service Manager with Ms Faye Barnes as Directorate Operation Manager, and Ms Sharon Wroe as Deputy Service Manager. We are currently in negotiations with the trust for a dedicated CPOC Service Manager.

Infrastructure development

In 2017, a fire caused serious irreparable damage to the Paterson Research Building at The Christie, leading to the displacement of over 300 scientists and research staff. Whilst causing setbacks in world-leading research activities, the fire gave rise to a new opportunity to create a brand new £150 million globally leading cancer research facility. The new Patterson facility lends promise to scientific collaboration and a transformation in cancer patient outcomes. It is a critical development in The Christie’s journey to become one of the top five preclinical, translational and clinical cancer centres in the world. This new facility is designed to support our

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Service Report 2022 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust

translational approach to cancer research and care, by promoting the interaction, integration and collaboration between research and clinical staff through co-location. As a result, joint research programmes will be stimulated that tackle some of the most important challenges. It is also a public facing facility to aiming to promote health education and awareness about cancer. The new building, with its state-of-the-art facilities and with the research it supports will also act as an important tool in attracting new talent from all over the world. The building will be twice the size of its predecessor, bringing together the largest concentration of scientists, doctors and nurses in Europe. A further 400 staff will be supported by the facility, alongside the 350 research scientists and support staff who are currently displaced. The Patterson is due to be completed in December 2023 with an anticipated move in date of April 2023. 3.1 Patient Day Our annual patient support day was due to be held 21 st April 2022, however we took the decision to delay this until the 29 th of September 2022, which will allow us to hold the event face to face. We last ran a virtual patient day event on 21 st April 2021 which was a success, however feel that our patients would benefit more from meeting in person. There are many advantages to running virtual events such as increasing access for patients who cannot travel, and we therefore plan to run this as a hybrid event. Those who cannot attend in person this year will be able to join on a virtual platform. This year’s agenda is shown below: 3 PATIENT & PUBLIC ENGAGEMENT

Peritoneal Tumour Service Patient Day Thursday 29 th September 2022 Auditorium, Education Centre, Dept 17, The Christie

09.55

Introduction

Mr Aziz (Consultant) Peritoneal Tumour Service Lead

10.00

Welcome

10.15 10.45 11.15 11.30 12.00 12:30 14.00 14:30 15:00

Patient Story

Patient 1 Patient 2

Caring for your psychological well-being

Coffee Break

Research Dietician

Professor O’Dwyer (Consultant)

Ashleigh Maske

Lunch

Patient story – Living with PMP

Patient 3

Menopause

Dr Tara Kearney

Pseudomyxoma Survivor

Susan Oliver

Live Q&A Session (If you would like to ask an anonymous question, please use your smart phone and go onto www.sli.do event code: #PTPS)

Mr Wilson Professor O’Dwyer Mr Clouston

15:15

15:45

Close

Roger Spencer (Chief Executive)

3.2 Nurse Led Surveillance Telephone Follow up

Our nurse led telephone service for surveillance patients continues to go from strength to strength. Over the last year the CNS’s have performed 842 surveillance telephone consultations. We offered video

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Service Report 2022 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust

consultations during the pandemic but over time patients have prefer to do these on the telephone as it is more convenient in fitting into their daily lives.

In April 2021 we sent out a satisfaction survey for patients on telephone follow up to see how we could improve things. Out of 103 surveys sent 61 were returned with a lot of positive feedback. The results highlighted areas for improvement including:

• Checking at the end of the consultation whether a patient is happy to remain on telephone follow up • Writing directly to our patients with an account of the consultation including scan/blood test results.

Examples of survey results are shown below:

Overall, I am satisfied with the quality of the service being provided by the telephone follow up:

Strongly agree

45 74% 14 23%

Agree

Unsure

0 2 0

0% 3% 0%

Disagree

Strongly disagree

I could talk to the nurse easily and openly

Strongly agree

47 77% 13 21%

Agree

Unsure

1 0 0

2% 0% 0%

Disagree

Strongly disagree

I felt I could ask my nurse questions

Strongly agree

49 80% 10 16%

Agree

Unsure

1 1 0

2% 2% 0%

Disagree

Strongly disagree

Some of the comments we received about the telephone follow up service included:

“I think you provide a wonderful service and all staff are very approachable both face to face and on the telephone. Many thanks” “I prefer face to face appointments at the hospital” “ 5-star treatment always” “The telephone calls are always to the time stated which is very convenient” “In my last telephone consultation, I was told scan results. I would have appreciated those results in writing after the consultation” “I was very satisfied with telephone consultation, rather than travel to Christies”

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Service Report 2022 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust

3.3 Nurse Led Teaching Our CNS’s take part in the Surgical Nursing Study Days at The Christie which takes place every 3 months. We specifically teach on the disease, how each disease group is treated and how to manage post operative patients. We offer support to junior staff and encourage that they shadow us, so they understand the patient journey from the early stages. We have had some excellent feedback from our teaching sessions, and we thoroughly enjoy being able to share our knowledge and skills to assist in improving patient care:

“informative, interesting, engaging - found structure extremely helpful”

“Facilitators prepared very interesting presentations”

“Very relevant and useful training”

3.4 ePROMS (electronic Patient Related Outcome Measure Service)

The Christie has developed an electronic quality of life questionnaire using a platform called ePROMS to improve patient outcomes. This enables patients to complete a questionnaire at home using as online application which is quick and easy to use. A link to this is sent out to them prior to their consultation. Answers are colour co-ordinated with a key providing patients with advice if they are having problems which they should seek help for. The results can be accessed by the Clinicians via individal patient records on our clinical web portal (CWP). An example of a typical question frame is shown below:

The CPOC PTS has been one of the first services to bring this to surgery and piloted ePROMS in June 2021 on patients who had surgery between 2019 and 2020. The results are below. The numbers for the pilot study were relatively small however, we went live with this service in the Nurse led surveillance follow up clinics in January 2022.

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Service Report 2022 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust

Approximately 170 patients have completed an ePROM and feedback has been positive. This process has also highlighted issues that may not have been brought up in a general consultation due to their sensitive nature. One example is that we have been able to indentify a number of women who are having symptoms from an early menopause symptoms brought about abruptly due to a removal of their ovaries. We are now able to identify this at a meach earlier stage and as a result direct patients to discuss options such as HRT. We have also asked a consultant gynocologist specialising in menopausal symptoms (Dr Kearney) to speak at our patient day in September.

The ePROMS the questionnaires are specific to male and female patients, with the following themes addressed:-

• GI symptoms - Bowel habit, appetite, nausea/vomiting

• Stoma issues - Leaking/hernias/psychological impact

• Gynaecology issues - including menopausal symptoms

• Sexual function - erectile dysfunction/vaginal drynesss/loss of libido

• Psychological - tiredness, anxiety/depression

Financial concerns

•

Below are some examples of the results obtained for female patients: -

Tiredness

Grade 1 : I get better with a short rest

21 (78%)

Grade 2: I do not get better with a short rest which stops me from my daily activities (for example light housework or shopping) 6 (22%) Grade 3: As a result I struggle to care for myself (for example wash or shower) 0 (0%)

27 (42%)

Yes

Do you feel more tired than usual?

38 (58%)

No

Reduced libido

Blank/ Prefer not to say

22 (34%)

Has the disease or treatment affected your sex life (for the worst)? If yes, how much?

A little

1 (7%)

Quite a bit

8 (57%) 5 (36%)

Yes

14 (21%)

Very much

No

29 (45%)

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Service Report 2022 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust

Financial difficulties

Blank/ Prefer not to say

5 (8%)

Have your physical or medical condition caused you financial difficulties?

Yes 3 (75%) No 1 (25%) Yes 3 (30%) No 7 (70%)

Yes 4 (29%)

Helped with financial difficulties?

14 (21%)

Financial advice?

Yes

No 10 (71%)

Require any further input/advice?

46 (71%)

No

3.5 Complaints

Any formal complaints or PALS (Patient Advice and Liaison service) enquiries are investigated by the relevant team members within the agreed Trust Response timeframes. Summary reports of any complaints received that month are included as a standard agenda item on the monthly PTS Business Meeting. All patient feedback is collected and discussed at our monthly PTS business meetings as a recurring agenda item. We did not receive any complaints in 21/22.

3.6 Compliments

Throughout the year, the team have received multiple messages, letters and cards from patients and their families praising the service. A number have also made significant contributions to our Charity in recognition of the care received. Some of the many positive comments received this year include: “(The team) have given my mum 18 months of active healthy living with dignity. I can’t thank you all enough. You are all very special people which I am sure you are surrounded by heartbreak and joy. Much love and gratitude” “ I am writing to thank you for your kindness and support which you gave me during my stay in The Christie Hospital. Also, for your patience when I spoke to you on the phone before and after my operation ….. The care that I received was first class and helped me greatly during difficult times especially with the pressure the NHS has been under with Covid ” “ I just wanted to thank you for all your help and support during our time with the Christie …. It gave us ten years which without you guys we probably would not have had. I will always be grateful for the care you all took of Darren and would like to let you know Darren thought highly of you and the support you gave him. Carry on the fantastic work and once again thank you all. ”

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Service Report 2022 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust

“ Following the successful surgery, the treatment I received from all the staff at The Christie was outstanding and it was obvious that (The Team) are held in high esteem by patients and peers alike. ”

3.7 Website & Social Media

The CPOC website (https://www.christie.nhs.uk/CPOC) continues to be used by patients, relatives, and medical professionals to access information about us, what we do, conditions we treat, the patient journey, and information for professionals. Our news section is updated every week with stories relating to the team, our patients, awards, and research.

We have a social media presence on Linked In, Facebook, and Twitter through The Christie NHS Foundation trust media department who manage these posts and responses.

Our website is currently being updated based on the results and the requirements of our patients. Individual patients have been asked for testimonials and we will be filming some patient experience videos once we are able to do so.

3.8 Accomodation

Since 2019 Pseudomyxoma Survivor charity has supported our patients and their relatives with accommodation in S tay City apartments in Manchester City Centre. Our patients’ stay take s priority over the general public and there is a floor dedicated to them including a communal lounge. All apartments are self

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Service Report 2022 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust

catering and patients get a welcome card and a blanket courtesy of Pseudomyxoma Survivor. We have received positive feedback from patients and their relatives regarding this service.

3.9 Fundraising & Donations

Our patients and staff regularly fundraise for our service with donations received by The Christie Charity an placed into a dedicated CPOC peritoneal tumour fund. In 2021 Mr Aziz Ran in the first the London Marathon since the pandemic, and Prof Mark Saunders and Dr Rohit Kochhar did the 3 Peaks Challenge (a 24 mile hike across 3 tallest peaks in Yorkshire) for the Steve Prescott Foundation. In total £110,400 in donations were received by the CPOC peritoneaul tumour fund in 21-22.

3.10 Awards for patient care

In 2021 The Christie CPOC was awarded the following:

• HSJ Partnership Awards (2021) - Local Response to COVID- 19’ Category – Highly Commended • The Christie NHS FT: You have made a difference award - Winner • The Christie NHS FT: You have made a difference award - Nominee

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Service Report 2022 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust

4 EDUCATION & TRAINING

4.1 Fellowships

CPOC continues to be a place where specialists from across the UK and the world travel to train and gain invaluable experience in peritoneal tumour management and research.

4.1.1 RCS/ACPGBI Advanced Colorectal Malignancy Fellowship - Branded through the Royal College of Surgeons and the Association of Coloproctology of GB&I, we have had 3 fellows to date with excellent feedback from senior post-CCT UK trainees. Our 20/21 fellow (Ms Sarah Hassan) has been appointed as a consultant colorectal surgeon in Royal Derby Hospital from October this year, 21/22 fellows (pictured below) are Mr Nigel Day (appointed consultant colorectal surgeon at Epsom & St Helier’s Hospitals) and Mr Christopher Kearsey (appointed locum consultant at Royal Preston Hospital). Both will take up these posts in 2022. 4.1.2 European Society of Peritoneal Surgical Oncology (ESPSO) Fellowship: CPOC has been designated by the European Society of Surgical Oncology as a recognised training centre in peritoneal oncology since 2015. To date, we have mentored 9 Fellows registered through this program from the UK and abroad. 4.1.3 Postgraduate Institute of Medicine (Sri-Lanka) Fellowship: We continue to receive an international fellow from Sri Lanka to travel to the UK for overseas training. These fellows have completed their training and are put forward to travel to the Christie for postgraduate specialisation in surgical oncology for a year. Our current fellow is Mr Chamila Lakmal. 4.1.4 National Board of Examiners (India) International Fellow in Surgical Oncology: We continue to appoint an international fellow through a competitive process of selection from The Ganga Ram Hospital in India. Our current fellow is Mr Mayank Mathur. 4.1.5 National Institute of Healthcare Research (NIHR) Academic Clinical Lecturer: We have appointed an ST4 surgical trainee (Ms Meera Patel) developing a career as an independent academic surgeon and helped her apply for this NIHR ACL. Her clinical training is based at the Northwest of England Deanery and academic project on peritoneal metastases from colorectal cancer is based at the CPOC lab in the Manchester Cancer Research Centre. She is on track to apply for a clinician scientist grant application at the end of her specialist training.

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Service Report 2022 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust

4.1.6 European Society of Medical Oncology (ESMO) Fellowship: Dr Madeleine Strach is a medical oncologist specialising in the management of Appendix Adenocarcinomas who was successful in secure this competitive fellowship and spend 2 years with us as part of her PhD. Clinically she has joined our CPOC oncology team and academically she has set us a collaborative research programme studying the genomics of appendix adenocarcinomas between The CPOC Lab (University of Manchester), University of Sydney and Chris O'Brien Lifehouse Cancer Hospital in Sydney Australia. The Christie CPOC is a reference centre for units training in CRS/HIPEC. One of the route through which we deliver this involves a memorandum of understanding between The Christie and RanD to join their academy of training centres. To date we have trained international teams from India, Brazil, Pakistan, Mexico, and Jordan). The latest a peritoneal tumour service we have helped set up is in the Middle East at The King Hussein Cancer Centre (KHCC), Jordan. This involved training the team in Manchester over 2 years and operating with them in Amman. The Christie CPOC remains a reference centre for training in laparoscopic CRS/HIPEC and have joined the Perito neal Surface Oncology Group International’s (PSOGI) laparoscopic CRS/HIPEC registry as one of the single largest contributors of this procedure in the world. We have supported our gynaecologists to undertake a pilot of 14 cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) procedures for ovarian cancer funded through an NHS business cases (9 patients) and privately (5 patients). This places The Christie in a position to participate in the OVIPEC II randomised controlled trial. We are also currently evaluating the resources required for this service to be set up at The Christie should there be an NHS-commissioning framework for CRS/HIPEC in ovarian cancer in the future. 4.2 RanD Academy 4.3 CRS/HIPEC for Ovarian Cancer

4.5 Education/Courses

In June 2021 we organised a virtual study day entitled : ‘ Appendix Tumours: Who to refer and what to expect ’ , led by Mr. Wilson. This event was aimed at UK colorectal MDT members to bring them up to speed with guidelines, evidence, outcomes, and referral pathways for these rare tumours. In April 2022 we delivered a Cheshire and Mersey Regional Training event on ‘ Rare Tumours for the Colorectal and General Surgeon’ organised by Mr Sutton.

4.4 Academic meetings

We hold monthly virtual academic meetings which have successfully included both clinical and basic science topics. Whilst not all of these are related to peritoneal tumours, we have at least 4 per year which are. Attendance at these meeting has ranged between 30-60 participants. We invited the team from PMI Basingstoke to attend our December meeting which a great success. Key peritoneal tumour related topics have included:

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Service Report 2022 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust

• “ Ultrasound guided day case percutaneous wide bore aspiration of Pseudomyxoma peritonei ” presented by Dr Philip Borg (Consultant Interventional Radiologist, The Christie Hospital NHS Foundation Trust) & “ The BROAC-TRIAL: a supportive role for Bromelain and Acetylcysteine in advanced PMP ” presented by Dr Lidia Rodríguez Ortiz (University Hospital Reina Sofia, Spain) and Dr Arjona Sanchez (University Hospital Reina Sofia, Spain) – Dec 2022 • “ Adenocarcinoma of the appendix - Outcomes from CRS HIPEC at The Christie ” presented by Dr Strach (University of Manchester) & “ CRUK Accelerator project (Pseudomyxoma peritonei: building a European multicentric cohort to accelerate new therapeutic perspectives) update ” presented by Dr Barriuso – April 2022 • “ The T cell receptor repertoire of tumour infiltrating T cells: an introduction " presented by Dr Sara Valpione & “ The quantification of T cell infiltration and clonality identifies distinct prognostic groups in colorectal cancer ” presen ted by Dr Luca G. Campana - September 2021 • “ The Role of JAK/STAT3 cascade in colorectal cancer " presented by Professor Joanne Edwards (University of Glasgow) & “ Is the microenvironment the key to stratify patients with CRPMs? " presented by Dr Jorge Barriuso - May 2021

• ‘ Histopathology and Classification of Appendiceal Tumours ’ Dr B Chakrabarty, March 2021

• Prodige 7 trial paper & NIHR EVidencE Review of PEritoneal Tumour (EVERPET) project Mr Aziz , Prof Kurunchi - February 2021

• “ Proteomics: Potential for advanced biomarker discovery ” . Dr. Richard Unwin (Deputy Director, Stoller Biomarker Discovery Centre) & Professor Paul Townsend (co-Director of Manchester Centre for Cellular Metabolism), University of Manchester. February 2020

5 RESEARCH

We continue to expand our research portfolio. Over the past year we have established The Christie Colorectal and Peritoneal Oncology Centre (CPOC) Academy and Lab, at theManchester Cancer Research Centre. Despite the challenges of the pandemic, we have grown our collective research team which now comprises of; 5 PhD students, an academic clinical lecturer (50% clinical/50% academic), an ESMO fellow, 2 postdoctoral research fellows, and a research manager. This team is funded through the grants listed in section 5.5. Our key research themes include:

Biomarker research

•

Technology and Innovation

•

• Clinical outcomes and treatment effects

5.1 Biomarker Research

5.1.1 Cancer Research UK Accelerator Award: Pseudomyxoma peritonei: building a European multicentric cohort to accelerate new therapeutic perspectives – We are one of three European groups (including Italy and Spain) that have been awarded this prestigious award to accelerate the collection of a

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Service Report 2022 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust

comprehensive biobank of tissue from patients with pseudomyxoma peritonei (PMP) from Low grade appendiceal mucinous neoplasms (LAMNs) over 5 years.

The £2.5m award aims to identify genomic biomarkers, build in vitro 3-D models and organoids, and ultimately establish a platform to identify therapeutic options for PMP patients. Our team includes faculty from across The University of Manchester including; CPOC Lab at The Manchester Cancer Research Centre, Wellcome Trust Centre for Cell Matrix, School of Pharmacology, and Manchester Centre for Genomic Medicine. The project has to date established a standardised biobank collection process, tumour sampling, DNA and RNA extraction across the 3 countries including a quality control check. We have successfully standardised live tissue processing and cell culture leading to the development of LAMN and appendix adenocarcinoma in vitro models and organoids. Currently we are establishment of libraries of information that can be shared with researchers across the world to accelerate our understanding of LAMNs leading to PMP and optimising bioinformatics pipelines to look at this data. 5.1.2 Dysregulated pathways in ColoRectal cancer Peritoneal Metastasis (CRPM): Funding secured from The Christie Charity has allowed us to establish our CRPM biomarker research program. Our comprehensive analysis of samples from peritoneal metastases with their matched colorectal cancer primaries obtained during cytoreductive surgery has been tested and validated leading to the identification of 20 genes dysregulated in peritoneal metastases that promote an early increasing role of "stemness" in conjunction with tumour favourable inflammatory changes. Our findings have indicated that the activation of these pathways, and adaptation to the peritoneal-specific environment are key to early stages of peritoneal metastasis. We have now secured funding to increase our sample size to 200 patients, looking for prognostic signatures, and exploring these pathways to look for therapeutic options. Finally, we have also secured funding for a project on whole exome sequencing of primary colorectal cancers and their peritoneal metastases working with Professor David Wedge.

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Service Report 2022 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust

5.2 Technology and Innovation

5.2.1 Mass Spectrometry to characterise lipid profiles of CRPM: Mass spectrometry is a very powerful tool, used to rapidly and reliably characterise tissue. We have established a partnership between Waters Corporation (A leading mass spectrometer manufacturer), The University of Manchester, and The Christie CPOC to characterise colorectal peritoneal metastases using this powerful tool. Funded by the Medical Research Council, we have a PhD student whose project involves characterising the lipid profiles of these tumours. This is a platform for future research in this area which has implications not only for the understanding of the peritoneal environment as a metastatic site, but also for the development of rapid tools that tell the surgeon in real- time whether a tissue is ‘tumour’ or ‘normal’. The project aims to have a mass spectrometer installed in an operating theatre for real-time tissue characterisation. 5.2.2 Prehabilitation with wearables before CRS/HIPEC: A randomised controlled pilot study. Having undertaken a systematic review of prehabilitation programs in abdominal cancer surgery, we have designed and completed the first randomised controlled trial of prehabilitation delivered solely with wearable devices versus standard of care in patients undergoing CRS/HIPEC. Funded through a donation from the charity ‘Pseudomyxoma Survivor’, we were able to achieve 67% recruitment. The prehabilitation group engaged in more daily minutes of moderate and vigorous physical activity compared to controls. They also had significantly greater improvements in the distance they could walk in 6 minutes compared to controls (+ 85.6 m vs + 13.23 m, p = 0.014]. We have now designed a larger randomised control trial in this group to quantify the impact of this improvement on post operative recovery. We have secured a grant fromManchester Academic Health Science Centre and Pseudomyxoma Survivor charity to build a prehabilitation Mobile phone App combined with wearables. 5.3.1 EVidencE Review of PEritoneal Tumours (EVERPET) is a 3-year NIHR-funded project between University College London and The Christie CPOC that started in 2019. This project aims to comprehensively evaluate the evidence for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for peritoneal metastases of colorectal, ovarian, gastric and appendiceal origins through individual patient data meta-analysis of clinical trials. More information can be found at: https://everpetwg.com/ 5.3.2 Outcomes research for patients with peritoneal metastasis: We continue to publish and share our outcomes with the international community. Projects include indications and outcomes for repeat CRS/HIPEC in peritoneal surface malignancy, Referral pathways and outcome of patients undergoing CRS/HIPEC, and Radiological patterns of recurrence after CRS/HIPEC for CRPM. 5.3.3 Early identification of LAMNs at risk of PMP: We have one of the world’s largest patient groups with early LAMNs referred through our established network over the past decade. Our research in this area includes: The Long-term outcomes for pTis and pT3 non-perforated LAMNs on an active 5.3 Clinical outcomes and treatment effects

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Service Report 2022 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust

surveillance pathway and outcomes from Laparoscopic CRS/HIPEC for perforated LAMNs. We are a major contributor to the PSOGI international collaborative laparoscopic CRS/HIPEC registry which has published its results.

5.4 Conferences and Meetings

ACPGBI Annual Conference 2022

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o “Appendiceal adenocarcinoma treated at a national peritoneal tumour centre” (Verbal and Poster) (M Strach, J Barriuso, B Chakrabarty, S O’Dwyer, O Aziz) o “Investigating the role of the extracellular matrix in the peritoneal dissemination of pseudomyxoma pe ritonei” (Poster) (M McAllister, O Aziz, D Thornton, S O’Dwyer, & P Caswell) o “Proteomics profile and quantitation of pharmacokinetics (PK) and pharmacodynamics (PD) targets in liver, small intestine, colon, and peritoneal cancer” (Poster) (A -M Vasilogianni, O Aziz, S O'Dwyer, J Barriuso, C Demonacos, SA Peters, A Rostami-Hodjegan, J Barber) o “Patterns and Timing of recurrence following CRS and HIPEC in Colorectal Cancer Peritoneal Metastasis” (Poster) (Sarah)

• Karolinska Institute Rectal Cancer Forum 2022

o “Developing an extension to the CR29 for rectal patients having organ preserving treatment” (Poster) (A Gilbert, R Fish)

• European Association for Clinical Pharmacology and Therapeutics 2022

o “Quantitative Proteomics of Hepatic Drug -Metabolizing Enzymes and Transporters in Patients with Colorectal Cancer Liver Metastasis” (Oral) (A‐M Vasilogianni, Z M Al‐Majdoub, B Achour, S A Peters, J Barber, A Rostami‐Hodjegan)

• The Centre for Applied Pharmacokinetic research (CAPKR) Annual Meeting 2022

o “The Human Appendix Is Not There To Be Ignored” (Oral) (A‐M Vasilogianni)

ACPGBI Annual Conference 2021

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o “IntraPeritoneal Disease -Free Survival after complete cytoreductive surgery and HIPEC for colorectal peritoneal metastases”.(Published) (H Clouston, J Convill, O Aziz, J Wild, C Selvasekar, M S Wilson, S O’Dwyer, A Renehan) o “Complications following complete cytoreductive surgery and HIPEC for colorectal peritoneal metastases: a UK national treatment centre experience compared with recent trial outcomes”. (Published) (H Clouston, J Convill, O Aziz, M Saunders, J Barriuso, M S Wilson, Sarah O’Dwyer, A Renehan) o “Average cumulative relative dose (ACRD) of adjuvant chemotherapy is more important than average relative dose intensity (ARDI) for colorectal cancer survival, with implications for treating obese patients: the OCTOPUS con sortium”. (Poster) (C Slawinski, L Malcomson, H Guo, J Barriuso, A Harkin, T Iveson, R Glynne-Jones, C van de Velde, A Renehan)

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Service Report 2022 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust

o “The molecular biology of synchronous primary colorectal cancer and their peritoneal metastases treated with Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC)”. (Published) (J Barriuso, RT Nagaraju, S Belgamwar, B Chakrabarty, DG Evans, MP Saunders, S O'Dwyer, O Aziz) o “Radiological patterns and timing of recurrence following complete cytoreductive su rgery and hyperthermic intraperitoneal chemotherapy in patients with Colorectal Cancer Peritoneal Metastases”. (Published) (S Hassan, Y J Soh, O Aziz, H Clouston, J Wild, C Selvasekar, M S Wilson, S O’Dwyer, A G Renehan, R Kochhar) o “Long -term outcomes for pTis and pT3 non-perforated low-grade appendiceal neoplasms on an active surveillance pathway”. (Published) (C Tan, B Chakrabarty, J Wild, C Selvasekar, A Renehan, H Clouston, MWilson, S O’Dwyer, O Aziz) o “Peritoneal recurrence following appendicectomy for perforated low-grade mucinous appendiceal neoplasms: evaluation of a dual strategy of watch-and-wait and risk-reducing cytoreductive surgery and heated intraperitoneal chemotherapy”. (Published) (B Aljalabneh, J Wild) o “Colorectal Liver Metastases - Novel Assessment Tools for Resectability (The CoNoR Study): Results from an International Questionnaire of Hepatopancreatobiliary Surgeons”. (Published) (K Parmar, D O’Reilly, R Jones, M Braun, J Valle, A Renehan)

ALSGBI Annual conference 2021

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o “Single institute experience on robotic vs laparoscopic vs open approach to abdominoperineal excision of rectum and anus (APER) – M Mathur, C Selvasekar.

o “Robotic approach to low rectal cancer making LAR possible” – M Mathur, C Selvasekar.

ASGBI Annual Conference 2021

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o “Lap aroscopy in Emergency General Surgery (The LEGS Study): NELA Database Analysis - Comparison of Outcomes in Laparoscopic versus Open Surgery”. (E -Poster) (K Parmar, E Badrick, L Malcomson, AG Renehan, A Sharma, N Heywood)

BAPIO conference 2021

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o “ Massive appendix Mucocole presenting and left upper quadrant mass ” (Poster) – M Mathur, C Selvasekar.

o “Tertiary Centre experience of robotic abdominoperineal excision of rectum and anus (APER) in locally advanced rectal cancer” (Poster) – M Mathur, C Selvasekar.

• European Society of Medical Oncology 2021

o “Average cumulative relative dose (ACRD) of adjuvant chemotherapy is more important than average relative dose intensity (ARDI) for colorectal cancer survival, with implications for

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Service Report 2022 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust treating obese patients: the OCT OPUS consortium”. (Oral) (C Slawinski, L Malcomson, H Guo, J Barriuso, A Harkin, T Iveson, R Glynne-Jones, C van de Velde, A Renehan)

• International Multidisciplinary Anal Cancer Conference – IMACC 2021 2021

o “ CORMAC-2: International consensus to define outcomes for trials of chemoratiotherapy for anal cancer (CORMAC-2): Defining the outcomes from the CORMAC core outcome set ” (Oral and Poster) (Samuel R, Sebag-Montefiore D, Adams R, Hawkins M, Williamson P, Das P, Dorth J, Guren M, Renehan A , Fish R)

Manchester Medical Society 2021

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o “Radiological patterns and timing of recurrence following complete cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with Colorectal Cancer Peritoneal Me tastases”. (Oral) (S Hassan, Y J Soh, O Aziz, H Clouston, J Wild, C Selvasekar, M S Wilson, S O’Dwyer, A G Renehan, R Kochhar) o “Peritoneal recurrence following appendicectomy for perforated low -grade mucinous appendiceal neoplasms: evaluation of a dual strategy of watch-and-wait and risk-reducing cytoreductive surgery and heated intraperitoneal chemotherapy”. (Oral) (B Aljalabneh, J Wild) • Knowledge Asset Grant (2022), The feasibility of creating combined genetic, clinical and quality of life datasets in patients with locally recurrent rectal cancer (P Sutton, O Aziz, S O’Dwyer, Award value £24,000) • Manchester Academic Health Science Centre (MAHSC) (2021-2022), Development of a ‘prehabilitation’ App to improve patient post -operative outcomes. (O Aziz, J Saxton & J Allen, Award value £24,000) • Pseudomyxoma Survivor charity (2022-2023), Development of a ‘prehabilitation’ App to improve patient post-operative outcomes. (O Aziz, J Saxton & J Allen, Award value £22,000) • European Organisation for Research and Treatment of Cancer (2021-2024), EORTC QLG new module development- neoadjuvant treatment in rectal cancer (A Gilbert & R Fish, Award value 122,751 Euros) • European Society for Medical Oncology (2021-2024), Genomics of appendix adenocarcinoma (J Barriuso & O Aziz, Award value 40,000 Euros) • Marie- Skłodowska Curie ITN Early Stage Researcher (2020 -2023), ValCoRe: Value of Benefit from a new cancer treatment: clinical complete response in rectal cancer (A Renehan, Award value £211,202) • CRUK Accelerator Award (2020-2025), Pseudomyxoma peritonei: building a European multicentric cohort to accelerate new therapeutic perspectives (S O’Dwyer, J Barriuso &O Aziz, Award value £2.5m) • Christie Charity (2020- 2025), Colorectal and Peritoneal Oncology Academy (S O’Dwyer & O Aziz, Award value £375,000) • NIHR (2019-2022), Cytoreductive surgery with hyperthermic intraoperative peritoneal chemotherapy versus standard of care in people with peritoneal metastases from colorectal, ovarian or gastric origin:

5.5 Grants

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Service Report 2022 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust

Systematic review and individual participant data meta-analyses of effectiveness and cost effectiveness (S O’Dwyer & O Aziz, Award value £305,636) • NIHR RfPB (2019-2022), (PrefCoRe): Quantifying and implementing preferences for the treatment of high-risk rectal cancer (A Renehan, Award value £248,879) • Ileostomy Association/Medtronic (2019-2021), DiSCO- Defining standards in colorectal prehabilitation. (R Fish, Award value £10,488) • MRC National Productivity Investment Fund (2017-2022), Mass Spectrometry Imaging for Colorectal Cancer Subtype Classification (O Aziz, Award value £75,000) • NIHR (2017-2020) Single Use Negative pRessure dressing for Reduction In Surgical site infection following Emergency laparotomy- the SUNRRISE Trial (H Clouston, Award value £345,669) • Abudeeb H, Selvasekar CR, O'Dwyer ST, Chakrabarty B, Malcolmson L, Renehan AG, Wilson MS, Aziz O. Laparoscopic cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for perforated low-grade appendiceal mucinous neoplasms. Surg Endosc. 2020 Dec;34(12):5516-5521. doi: 10.1007/s00464-019-07349-x. Epub 2020 Jan 28. PMID: 31993814; PMCID: PMC7644477. • Arjona-Sanchez A, Aziz O, Passot G, Salti G, Esquivel J, Van der Speeten K, Piso P, Nedelcut DS, Sommariva A, Yonemura Y, Turaga K, Selvasekar CR, Rodriguez-Ortiz L, Sanchez-Hidalgo JM, Casado Adam A, Rufian-Peña S, Briceño J, Glehen O. Laparoscopic cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for limited peritoneal metastasis. The PSOGI international collaborative registry. Eur J Surg Oncol. 2020 Dec 2:S0748-7983(20)31036-2. doi: 10.1016/j.ejso.2020.11.140. Epub ahead of print. PMID: 33298341. • Barriuso J, Nagaraju RT, Belgamwar S, Chakrabarty B, Burghel GJ, Schlecht H, Foster L, Kilgour E, Wallace AJ, Braun M, Dive C, Evans DG, Bristow RG, Saunders MP, O'Dwyer ST, Aziz O. Early Adaptation of Colorectal Cancer Cells to the Peritoneal Cavity Is Associated with Activation of "Stemness" Programs and Local Inflammation. Clin Cancer Res. 2021 Feb 15;27(4):1119-1130. doi: 10.1158/1078-0432.CCR 20-3320. Epub 2020 Nov 30. PMID: 33257424. • Campana LG, Fisher R, Dickinson OT, McNamara M, O'Dwyer ST, Laasch H-U. Distal migration of a partially covered duodenal stent requiring emergency surgical extraction. International Journal of Gastrointestinal Intervention. 2021 Oct 21. • Dames NB, Squire SE, Devlin AB, Fish R, Bisset CN, Tozer P; Respondents to the Sex After Colorectal Surgery Survey. 'Let's talk about sex': a patient-led survey on sexual function after colorectal and pelvic floor surgery. Colorectal Dis. 2021 Feb 22. doi: 10.1111/codi.15598. Epub ahead of print. PMID: 33615666. • Dodd S, Fish R, Gorst S, Hall D, Jacobsen P, Kirkham J, Main B, Matvienko-Sikar K, Saldanha IJ, Trépel D, Williamson PR. Representation of published core outcome sets for research in regulatory guidance: protocol. HRB Open Res. 2021 Aug 2;4:45. doi: 10.12688/hrbopenres.13139.3. PMID: 34368618; PMCID: PMC8311813.

5.6 Publications

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Service Report 2022 Colorectal and Peritoneal Oncology Centre – The Christie NHS Foundation Trust

• Evans T, Aziz O, Chakrabarty B, Wilson MS, Malcomson L, Lavelle C, O'Dwyer ST. Long-term outcomes for patients with peritoneal acellular mucinosis secondary to low grade appendiceal mucinous neoplasms. Eur J Surg Oncol. 2021 Jan;47(1):188-193. doi: 10.1016/j.ejso.2020.10.020. Epub 2020 Oct 16. PMID: 33092969. • Fish R. Ovarian transposition in rectal cancer: uncertain benefit at a high price. Colorectal Dis. 2022 Mar 6. doi: 10.1111/codi.16086. Epub ahead of print. PMID: 35249247. • Gurusamy K, Vale CL, Pizzo E, Bhanot R, Davidson BR, Mould T, Mughal M, Saunders M, Aziz O, O'Dwyer S. Cytoreductive surgery (CRS) with hyperthermic intraoperative peritoneal chemotherapy (HIPEC) versus standard of care (SoC) in people with peritoneal metastases from colorectal, ovarian or gastric origin: protocol for a systematic review and individual participant data (IPD) meta-analyses of effectiveness and cost-effectiveness. BMJ Open. 2020 May 12;10(5):e039314. doi: 10.1136/bmjopen 2020-039314. PMID: 32404398; PMCID: PMC7228534. • Lamarca A, Clouston H, Barriuso J, McNamara MG, Frizziero M, Mansoor W, Hubner RA, Manoharan P, O'Dwyer S, Valle JW. Follow-Up Recommendations after Curative Resection of Well-Differentiated Neuroendocrine Tumours: Review of Current Evidence and Clinical Practice. J Clin Med. 2019 Oct 5;8(10):1630. doi: 10.3390/jcm8101630. PMID: 31590343; PMCID: PMC6833016. • Larentzakis A, O'Dwyer ST, Becker J, Shuweihdi F, Aziz O, Selvasekar CR, Fulford P, Renehan AG, Wilson M. Referral pathways and outcome of patients with colorectal peritoneal metastasis (CRPM). Eur J Surg Oncol. 2019 Dec;45(12):2310-2315. doi: 10.1016/j.ejso.2019.07.008. Epub 2019 Jul 4. PMID: 31433300. • Parkin E, Selvasekar C, Wilson M, Renehan A, O'Dwyer S, Aziz O. Laparoscopic Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy (L-CRS/HIPEC) for Perforated Low-Grade Appendiceal Mucinous Neoplasm (LAMN II). Ann Surg Oncol. 2019 Jul;26(7):2285. doi: 10.1245/s10434-019-07277-z. Epub 2019 Apr 15. PMID: 30989495. • Pearson I, Blackwell S, Fish R, Daniels S, West M, Mutrie N, Kelly P, Knight S, Fearnhead NS, Moug S. Defining standards in colorectal optimisation: a Delphi study protocol to achieve international consensus on key standards for colorectal surgery prehabilitation. BMJ Open. 2021 Mar 24;11(3):e047235. doi: 10.1136/bmjopen-2020-047235. PMID: 33762250; PMCID: PMC7993327. • PelvEx Collaborative. Management strategies for patients with advanced rectal cancer and liver metastases using modified Delphi methodology: results from the PelvEx Collaborative. Colorectal Dis. 2020 Sep;22(9):1184-1188. doi: 10.1111/codi.15007. Epub 2020 Mar 2. PMID: 32043753. • PelvEx Collaborative. Simultaneous pelvic exenteration and liver resection for primary rectal cancer with synchronous liver metastases: results from the PelvEx Collaborative. Colorectal Dis. 2020 Oct;22(10):1258-1262. doi: 10.1111/codi.15064. Epub 2020 May 12. PMID: 32294308. • PelvEx Collaborative. The impact of the COVID-19 pandemic on the Management of Locally Advanced Primary/Recurrent Rectal Cancer. Br J Surg. 2020 Oct;107(11):e547-e548. doi: 10.1002/bjs.11893. Epub 2020 Aug 10. PMID: 32779191; PMCID: PMC7436568.

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