We note the comments by Scott et al on our paper and present the following information to answer their points.

First, two authors are clinically qualified and have extensive experience in colorectal cancer (Professor Quirke) and oncology (Dr Cottier). Professor Quirke has been asked on two occasions to participate in the development of guidelines by the Association of Coloproctology of Great Britain and Ireland (ACPGBI) for the treatment of colorectal cancer. Interestingly, in the latest guidelines issued by this professional body recommendations were made as to the upper acceptable frequency of abdominoperineal excision (APE) procedures which was set at 30%.1 One in three NHS trusts exceeded this figure in our paper.

Second, the authors state that we assert that APE automatically leads to a poorer quality of life than anterior resection (AR). We do not make this claim but express the view that some patients may needlessly receive an APE which could potentially lead to a poorer quality of life, a higher risk of local recurrence, poorer survival and increased costs. The papers we cite as evidence support this statement. The Cochrane review on quality of life does not flatly contradict our statement but states that no firm conclusions can be drawn due to the current weak evidence base.2 Other papers we cited (which were co-authored by two of the signatories to the letter by Scott et al) demonstrate that patients who undergo APE have an increased incidence of local recurrence and a 10% increase in mortality compared to patients who receive AR.2^–5 While quality of life is important it can only be collected from living patients.

We fully accept that some important case-mix factors were absent from our analyses and discussed this …