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Created May 21, 2015, last updated about 3 years ago.
Collection: 2, Score: 1873, Trend score: 0, Read count: 2253, Articles count: 14, Created: 2015-05-21 01:34:14 UTC. Updated: 2021-11-03 23:21:01 UTC.Notes
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Collected Articles
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Randomized Controlled Trial
Differential effects of serum from patients administered distinct anaesthetic techniques on apoptosis in breast cancer cells in vitro: a pilot study.
In vitro and retrospective clinical studies suggest an association between anaesthetic technique during primary breast cancer surgery and cancer outcome. Apoptosis is an important step in the mechanism of breast cancer metastasis, but whether it is influenced by anaesthetic technique is unknown. Using serum from breast cancer surgery patients randomized to receive distinct anaesthetic techniques, we investigated its effect on apoptosis in oestrogen receptor (ER)-negative breast cancer cells in vitro. ⋯ Serum from patients given sevoflurane anaesthesia and opioids for primary breast cancer surgery reduces apoptosis in ER-negative breast cancer cells to a greater extent than serum from patients given propofol-paravertebral anaesthesia. Anaesthetic technique might affect the serum milieu in a manner that impacts cancer cell apoptosis, and thereby tumour metastasis.
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Anesthesia and analgesia · Oct 2017
Paravertebral Block Does Not Reduce Cancer Recurrence, but Is Related to Higher Overall Survival in Lung Cancer Surgery: A Retrospective Cohort Study.
Postoperative analgesic methods are suggested to have an impact on long-term prognosis after cancer surgery through opioid-induced immune suppression. We hypothesized that regional analgesia that reduces the systemic opioid requirement would be related to lower cancer recurrence and higher overall survival compared to intravenous patient-controlled analgesia (PCA) for lung cancer surgery. ⋯ Pain-control methods are not related to cancer recurrence. However, PVB may have a beneficial effect on overall survival of patients with lung cancer.
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Review Comparative Study
Outcomes of cancer surgery after inhalational and intravenous anesthesia: A systematic review.
Perioperative factors are probably essential for different oncological outcomes. This systematic review investigates the literature concerning overall mortality and postoperative complications after cancer surgery with inhalational (INHA) and intravenous anesthesia (TIVA). A search was conducted according to the PRISMA guidelines, including studies with patients undergoing surgery for cancer and where TIVA was compared with INHA. ⋯ In one study, the rate of pulmonary complications was significantly higher after INHA compared with TIVA, while other postoperative complications were comparable. There are currently four propensity-adjusted retrospective studies indicating that TIVA might be the preferred anesthetic choice in cancer surgery. However, evidence is currently of low quality and randomized clinical trials are required for further investigation.
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Randomized Controlled Trial Comparative Study
Effect of Equipotent Doses of Propofol versus Sevoflurane Anesthesia on Regulatory T Cells after Breast Cancer Surgery.
WHAT THIS ARTICLE TELLS US THAT IS NEW: BACKGROUND:: Clusters of differentiation 39 and 73, enzymes expressed on the surface of regulatory T cells, promote cancer recurrence and metastasis by suppressing immune cells. The authors hypothesized that propofol is less immunosuppressive than volatile anesthetics. The objective of this randomized trial was to compare the changes in cluster of differentiation 39 and 73 expression on regulatory T cells between propofol- and sevoflurane-based anesthesia during breast cancer surgery. ⋯ Changes in immune cells were similar with propofol and sevoflurane during breast cancer surgery. The effect of anesthetics on the perioperative immune activity may be minimal during cancer surgery.
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Comparative Study
Total Intravenous Anesthesia versus Inhalation Anesthesia for Breast Cancer Surgery: A Retrospective Cohort Study.
Cutting to the chase...
This large, retrospective study with propensity-matched controls found NO difference in breast cancer survival between inhalataional and intravenous anesthetic techniques.
Why is this still important?
Following Exadaktylos' eye-popping 2006 retrospective, along with a few in vitro studies, anesthetists have been a little anxious that anesthetic technique choice could potentially have a such significant effect on cancer recurrence. To date, other trials have not replicated Exadaktylos' original results.
What was studied this time?
Yoo et al performed a retrospective study of 5,331 breast cancer patients over a 8 year period, looking at the relationship between anesthetic technique and both 5-year recurrence-free and overall survival.
There was no difference for either survival metric between inhalational or intravenous anesthesia.
So does this settle it?
Not yet. Although large and high quality, this is still a retrospective study with all the compromises that this brings.
Be smart
While we await results from prospective, randomized trials, we should not be distracted by the magical promise of one technique over another, and instead address the very real impact that anesthesia can have on patient Return to Intended Oncological Therapy (RIOT).
summary -
This controversy-starting retrospective study reported a 30% reduction in 3 year recurrence-free survival after undergoing mastectomy for primary breast cancer in patients who received a traditional general anaesthetic with morphine analgesia, compared with those receiving a regional (paravertebral) technique.
Although plausible biological mechanisms have been suggested and even demonstrated in vitro, the huge treatment effect is yet to be replicated in better quality retrospective or prospective trials.
Evidence to date does not (yet) support this trial’s findings.
"An extraordinary claim requires extraordinary proof." – Marcello Truzzi
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Cochrane Db Syst Rev · Nov 2014
Review Meta AnalysisAnaesthetic techniques for risk of malignant tumour recurrence.
Surgery remains a mainstay of treatment for malignant tumours; however, surgical manipulation leads to a significant systemic release of tumour cells. Whether these cells lead to metastases is largely dependent on the balance between aggressiveness of the tumour cells and resilience of the body. Surgical stress per se, anaesthetic agents and administration of opioid analgesics perioperatively can compromise immune function and might shift the balance towards progression of minimal residual disease. Regional anaesthesia techniques provide perioperative pain relief; they therefore reduce the quantity of systemic opioids and of anaesthetic agents used. Additionally, regional anaesthesia techniques are known to prevent or attenuate the surgical stress response. In recent years, the potential benefit of regional anaesthesia techniques for tumour recurrence has received major attention and has been discussed many times in the literature. In preparing this review, we aimed to summarize the current evidence systematically and comprehensively. ⋯ Currently, evidence for the benefit of regional anaesthesia techniques on tumour recurrence is inadequate. An encouraging number of prospective randomized controlled trials are ongoing, and it is hoped that their results, when reported, will add evidence for this topic in the near future.
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Propofol TIVA may be associated with improved survival after colon cancer surgery when compared with desflurane inhalation anaesthesia.
pearl -
Randomized Controlled Trial Multicenter Study Comparative Study
Which Anesthesia Regimen Is Best to Reduce Morbidity and Mortality in Lung Surgery? A Multicenter Randomized Controlled Trial.
One-lung ventilation during thoracic surgery is associated with hypoxia-reoxygenation injury in the deflated and subsequently reventilated lung. Numerous studies have reported volatile anesthesia-induced attenuation of inflammatory responses in such scenarios. If the effect also extends to clinical outcome is yet undetermined. We hypothesized that volatile anesthesia is superior to intravenous anesthesia regarding postoperative complications. ⋯ This is the first multicenter randomized controlled trial addressing the effect of volatile versus intravenous anesthetics on major complications after lung surgery. No difference between the two anesthesia regimens was evident.
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Cancer metastasis reviews · Mar 2017
ReviewAnesthetic technique and cancer recurrence in oncologic surgery: unraveling the puzzle.
Surgery/anesthetic technique-stimulated immunosuppression in the perioperative period might cause an increase in cancer-related mortality. Whether anesthetic technique can affect the outcomes of cancer patients remains inconclusive. This review discusses data from the available literature on anesthetic techniques applied in oncologic surgery, the long-term outcomes of anesthetic technique, and their relation to survival and cancer recurrence. ⋯ Regional anesthesia (RA) protects CMI and diminishes the surgical neuroendocrine stress response by blocking afferent neural transmission that stimulates the HPA axis and SNS, decreasing the requirement for opioids and volatile anesthetics and thereby decreasing cancer recurrence. Preclinical and retrospective studies highlight a potential benefit of anesthetic technique in reducing cancer-related mortality and recurrence by attenuating immunosuppression following surgical treatment in patients with specific types of cancer. Several well-planned, prospective, randomized controlled trials (RCTs) are underway that may provide more conclusive and definitive results regarding the benefits of anesthetic technique on survival in oncologic surgery.
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Why is this important?
Suspicions that anesthetic technique impacts survival after cancer surgery continues to be both unanswered and psychologically weighty: are anesthetic choices undermining patient survival?
What did they do?
This Taiwanese research group conducted a retrospective cohort-study in a single hospital covering 10 years of elective hepatectomy patients, comparing propofol to desflurane anesthesia. Notably, hepatocellular carcinoma is one of the leading causes of cancer death in Taiwan.
And they found...?
TIVA propofol was associated with a dramatically better survival (hazard ratio 0.57 (0.38-0.59)), even in subgroup analysis dependent on staging.
Reality check
Although this finding is consistent with other observational studies across a range of cancers, the apparent size of the benefit (50% mortality reduction!) should give us pause.
Given inconsistent findings from a range of similar observational studies, it is unlikely that there is a real treatment effect of this magnitude.
While we await results from well-powered RCTs, the jury is still out on whether anesthesia choices impact any specific cancer surgery...
summary -
Randomized Controlled Trial Multicenter Study
Recurrence of breast cancer after regional or general anaesthesia: a randomised controlled trial.
What makes this a landmark study?
Since Exadaktylos’ (2006) extraordinary retrospective study showing a 30% reduction in breast cancer recurrence with a regional analgesia technique, we have been anxious to learn whether anaesthetic choice my impact cancer outcome.
Various in vitro studies suggested plausible explanations for how opioids and volatiles could promote cancer recurrence, although quality evidence remainded missing.
The Breast Cancer Recurrence Collaboration has filled this gap, setting out to answer this question with an international, multicenter, randomised controlled trial.
What did they do?
Over 12 years 2,132 women were enrolled and ranomised to either paravertebral block & propofol, or sevoflurane. Some in the paravertebral group were exposed to sevoflurane when required (17%), and did receive intraoperative fentanyl, although roughly half as much on average as the volatile group.
And they found?
There was no difference in cancer recurrence rate or persistent wound pain between groups. Even when analysing only patients who received no sevoflurane (83% of regional group) no difference was identified.
This does not mean that a paravertebral technique offers no benefit: it almost eliminated the need for volatile anaesthesia, reduced opioid demand and reduced post-operative nausea & vomiting – all positive outcomes. But it did not reduce cancer recurrence.
Be smart
This result cannot be generalised beyond breast cancer to more invasive, stress-inducing cancer surgery (eg. prostatectomy, pneumonectomy). Our knowledge of perioperative factors that depress host defences (surgical stress, volatiles and opioids) are still relevant when we consider how anaesthetic choices may contribute to improving patient outcomes.
Explore further...
Dig deeper with other articles collected in Anesthesia technique and cancer recurrence.
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Randomized Controlled Trial
Epidural Anesthesia-Analgesia and Recurrence-free Survival after Lung Cancer Surgery: A Randomized Trial.
Epidural analgesia for video-assisted thoracoscopic lung cancer surgery does not improve cancer recurrence or cancer-specific survival.
pearl -
Anesthesia and analgesia · Mar 2021
Meta AnalysisAnesthesia and Long-Term Oncological Outcomes: A Systematic Review and Meta-analysis.
Propofol-based TIVA may be associated with improved overall survival after cancer surgery than volatile anaesthesia.
pearl
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