LAUSR

In recent decades, the management of colorectal cancer has significantly evolved. These advancements have been reflected in the development of specialist units for advanced colorectal cancer including pelvic exenteration and/or cytoreductive surgery/hyperthermic intraperitoneal chemotherapy (CRSHIPEC) [1, 2]. Overall, approximately 20% of colorectal cancer cases have stage IV disease at presentation [3]. Advanced colorectal cancer represents a diverse group of patients with approximately 8%– 10% having peritoneal metastases at diagnosis, [1] and onefifth presenting with and/or developing liver metastases [2]. Historically, the presence of any of the above would have been considered as a terminal condition. Increasingly, aggressive surgical strategies such as CRSHIPEC and multivisceral resection including bony and/or vascular resections to clear the disease are being performed, and quickly becoming the standard of care in many countries [2]. There is now substantial evidence to show it impacts disease progression and mortality as part of a multimodality approach in “select” patients. Five year overall survival following CRSHIPEC range from 22% to 43.2% [1]. Similarly, 5year survival following simultaneous pelvic exenteration and liver resection for primary rectal cancer is reported at 44% [2]. Despite the extent of these resections, major morbidity (~35%) and hospital mortality (<2%) are low [1, 2]. What we consider to be “resectable” has changed dramatically, particularly with regard to colorectal liver metastases. Technological advancements in surgical instruments facilitate aggressive approaches to hepatic metastastectomy. Radiofrequency ablation may also be used as an adjunct, with curative treatment becoming possible in a growing proportion of patients [4]. During the same time period, the incidence of youngonset (<40 years) colorectal cancer has been increasing at an alarming rate [5]. Many younger patients present with advanced tumours, requiring multimodality tailored therapy, for which surgery remains the cornerstone [5]. Historically, surgical oncologists have used overall survival or progressionfree survival as the main surrogate “marker” for success. However, these markers do not adequately reflect all the concerns that patients have relating to functional and impaired quality of life (QoL) issues. While multivisceral surgery is the only treatment modality with curative potential, a substantial cohort will not achieve a “complete” cure [1, 2]. In particular, young patients are more likely to prioritize “cure” as their main goal. They are also more likely to tolerate and survive aggressive surgical and/or chemotherapeutic management strategies. Unfortunately, this cohort have the most to lose in terms of QoL due to digestive, urological or sexual dysfunction. In addition, they are also more exposed to familial, financial, social or psychological implications than older patients [6]. Numerous studies have shown that patients understand and value function and are willing to accept a higher risk of local recurrence in order to achieve improved functional outcomes [7]. It is clear that QoL needs to be central in multidisciplinary decisionmaking when considering radical surgical options. The IMPACT initiative, a collaborative programme between the Association of Coloproctology of Great Britain and Ireland (ACPGBI) and the Pelican Foundation, recognised this requirement. A twoyear programme aimed to increase awareness among multidisciplinary teams of contemporary treatment options for patients with advanced colorectal cancer. The programme placed special emphasis on the integration of palliative care as a “parallel” supportive care aid, and not just about endoflife care. All of this improves patient care and attempts to balance length and QoL [8]. A literature search observed that only five studies provide substantial data on postoperative QoL in patients undergoing CRSHIPEC for colorectal cancer, appendiceal and/or primary peritoneal malignancy [9– 13]. Considerable heterogeneity in the QoL tools and instruments utilized (EORTC QLQC30/CR29, FACTC, SF36), as well as collection timepoints impede any meaningful analysis. In addition, there remains no dedicated and/or validated QoL tool for post CRSHIPEC or pelvic exenteration assessment. Since 2000, there have been over 7,800 articles on CRSHIPEC, but there remains limited QoL outcome data, especially regarding its influence on the decision to operate. Contraindications to surgery are usually apparent and straightforward: high burden of disease, and risk of perioperative morbidity and/or mortality. Alternatively, QoL should represent a valid indication for surgery (in select cases), despite the presence of adverse tumour features or high tumour burden. Palliative debulking is known to impact QoL, helping to alleviate