Perception of nurses on the practice environment: experience from Malaysia

INTRODUCTION

Positive professional practice environments are crucial to safeguard a healthy and safe working conditions for health workforce, including nurses; so as to ensure provision of quality healthcare and safety of patient.

METHODS

This was a cross-sectional study to assess nurses' perceptions towards nursing practice environment and factors associated with their perceptions. A validated Practice Environment Scale of the Nursing Work Index (PESNWI) questionnaire was administered to nurses working in two Ministry of Health hospitals. The questionnaire comprises of five subscales: Participation, Foundation, Managers Support, Workforce Adequacy and Physician/Nurse Relations. Mean scores of >2.50 were considered as favourable, and ≤2.50 were considered as unfavourable. Simple linear and multiple linear regression analysis were employed to identify factors associated with their perceptions. Analysis was carried out using STATA version 14.0.

RESULTS

A total of 366 respondents took part in the study, with a response rate of 98.4%. Majority were working shift (89.6%) and working extended hours (62.3%). In general, the nursing practice environments were rated as favourable. Overall mean score was 2.90±0.03 and four out of five subscales' mean scores were >2.50. Foundation for quality nursing care was perceived as the most favourable subscale, while workforce adequacy was perceived as the least favourable. There were statistically significant association between working extended hours, doing double shift and working during day off with perceived unfavourable workforce adequacy.

CONCLUSION

Nursing practice environment was perceived as favourable in the studied hospitals. Policy makers, service providers, and hospital managers could explore further on human resource planning and management of nursing personnel to tackle the issue of nurse staffing in the country.

The validation study on a three-dimensional burn estimation smart-phone application: accurate, free and fast?

Background

Accurate total body surface area burned (TBSAB) estimation is a crucial aspect of early burn management. It helps guide resuscitation and is essential in the calculation of fluid requirements. Conventional methods of estimation can often lead to large discrepancies in burn percentage estimation. We aim to compare a new method of TBSAB estimation using a three-dimensional smart-phone application named 3D Burn Resuscitation (3D Burn) against conventional methods of estimation—Rule of Palm, Rule of Nines and the Lund and Browder chart.

Methods

Three volunteer subjects were moulaged with simulated burn injuries of 25%, 30% and 35% total body surface area (TBSA), respectively. Various healthcare workers were invited to use both the 3D Burn application as well as the conventional methods stated above to estimate the volunteer subjects’ burn percentages.

Results

Collective relative estimations across the groups showed that when used, the Rule of Palm, Rule of Nines and the Lund and Browder chart all over-estimated burns area by an average of 10.6%, 19.7%, and 8.3% TBSA, respectively, while the 3D Burn application under-estimated burns by an average of 1.9%. There was a statistically significant difference between the 3D Burn application estimations versus all three other modalities (p < 0.05). Time of using the application was found to be significantly longer than traditional methods of estimation.

Conclusions

The 3D Burn application, although slower, allowed more accurate TBSAB measurements when compared to conventional methods. The validation study has shown that the 3D Burn application is useful in improving the accuracy of TBSAB measurement. Further studies are warranted, and there are plans to repeat the above study in a different centre overseas as part of a multi-centre study, with a view of progressing to a prospective study that compares the accuracy of the 3D Burn application against conventional methods on actual burn patients.

Lower Respiratory Tract Adenoid Cystic Carcinoma: Its Management in the Past Decades

AIMS

Adenoid cystic carcinoma of the lower respiratory tract is a rare indolent neoplasm with prolonged survival, propensity for recurrences and metastasis years after initial therapy. We aim to study a 1,700-bed single tertiary academic hospital's long-term experience with ACC of the lower respiratory tract from the larynx to the lungs and review published literature on this subject.

MATERIALS AND METHODS

We analysed the clinicopathology, treatment options and outcome in 33 patients and reviewed the published literature over the last five decades.

RESULTS

The tumour has no gender predilection, a peak incidence in the fifth decade and is not related to smoking. Insidious symptoms are often treated as benign obstructive airway disease and infection; negative signs and normal chest X-rays delayed diagnosis. The tumour was distributed most commonly in the trachea followed by main bronchi, lobar bronchi and larynx. About 22% of patients required emergent bronchoscopic intervention to secure airway patency before definitive therapy with surgery or/and radiotherapy. A high proportion of resected specimens had positive margins. Overall survival and disease-free survival rates at 5 years were 81 and 62%, respectively, and at 10 years 70 and 54%, respectively. Prolonged good palliation was achieved for patients with unresectable lesions with radiation and wide armamentarium of endoscopic therapy.

CONCLUSIONS

In time, many patients eventually succumb to this disease. However, advances in medical skill and technology have prolonged survival while maintaining a good quality of life. Adenoid cystic carcinoma of the respiratory tract is a chronic life-long disease that may require interval intensive therapy. The challenge is to find the best therapeutic regimen aiming for a 'true' cure. Further study on the mutational landscape of adenoid cystic carcinoma may provide potential avenues for novel treatments to address a chemoresistant cancer.

Functions of TAp63 and p53 in restraining the development of metastatic cancer

Many tumours harbour mutations in the p53 tumour-suppressor gene that result in the expression of a mutant p53 protein. This mutant p53 protein has, in most cases, lost wild-type transcriptional activity and can also acquire novel functions in promoting invasion and metastasis. One of the mechanisms underlying these novel functions involves the ability of the mutant p53 to interfere with other transcription factors, including the p53 family protein TAp63. To investigate whether simultaneous depletion of both p53 and TAp63 can recapitulate the effect of mutant p53 expression in vivo, we used a mouse model of pancreatic cancer in which the expression of mutant p53 resulted in the rapid appearance of primary tumours and metastases. As shown previously, loss of one allele of wild-type (WT) p53 accelerated tumour development. A change of one WT p53 allele into mutant p53 did not further accelerate tumour development, but did promote the formation of metastasis. By contrast, loss of TAp63 did not significantly accelerate tumour development or metastasis. However, simultaneous depletion of p53 and TAp63 led to both rapid tumour development and metastatic potential, although the incidence of metastases remained lower than that seen in mutant p53-expressing tumours. TAp63/p53-null cells derived from these mice also showed an enhanced ability to scatter and invade in tissue culture as was observed in mutant p53 cells. These data suggest that depletion of TAp63 in a p53-null tumour can promote metastasis and recapitulate-to some extent-the consequences of mutant p53 expression.

A phase III randomized study of gemcitabine and cisplatin with or without PF-3512676 (TLR9 agonist) as first-line treatment of advanced non-small-cell lung cancer

BACKGROUND

This open-label phase III study assessed the addition of Toll-like receptor 9-activating oligodeoxynucleotide PF-3512676 to gemcitabine/cisplatin chemotherapy in patients with non-small-cell lung cancer (NSCLC).

PATIENTS AND METHODS

Chemotherapy-naive patients with stage IIIB or IV NSCLC were randomized (1:1) to receive six or fewer 3-week cycles of i.v. gemcitabine (1250 mg/m2 on days 1 and 8) and cisplatin alone (75 mg/m2 on day 1, control arm) or combined with s.c. PF-3512676 0.2 mg/kg on days 8 and 15 of each chemotherapy cycle and weekly thereafter until progression or unacceptable toxicity (experimental arm). No crossover was planned. The primary end point was overall survival (OS).

RESULTS

A total of 839 patients were randomized. Baseline demographics were well balanced. Median OS (11.0 versus 10.7 months; P=0.98) and median progression-free survival (PFS) (both 5.1 months) were similar between groups. Grade≥3 hematologic adverse events (AEs), injection-site reactions, and influenza-like symptoms were more frequently reported among patients receiving PF-3512676. At the first-interim analysis, the Data Safety Monitoring Committee recommended study discontinuation. Administration of PF-3512676 was halted based on efficacy futility and increased grade≥3 AEs (experimental arm).

CONCLUSIONS

Addition of PF-3512676 to gemcitabine/cisplatin chemotherapy did not improve OS or PFS but did increase toxicity.

Yttrium-90 internal pair production imaging using first generation PET/CT provides high-resolution images for qualitative diagnostic purposes

Yttrium-90 ((90)Y) internal pair production can be imaged by positron emission tomography (PET)/CT and is superior to bremsstrahlung single-photon emission CT/CT for evaluating hepatic (90)Y microsphere biodistribution. We illustrate a case of (90)Y imaging using first generation PET/CT technology, producing high-quality images for qualitative diagnostic purposes.

A phase II study evaluating the safety and efficacy of an adenovirus-ΔLMP1-LMP2 transduced dendritic cell vaccine in patients with advanced metastatic nasopharyngeal carcinoma

BACKGROUND

Individuals with metastatic Epstein-Barr virus (EBV)-positive nasopharyngeal carcinoma (NPC) continue to have poor outcomes. To evaluate the ability of a dendritic cell (DC) vaccine to target subdominant EBV antigens LMP1 and LMP2 expressed by NPC cells, we vaccinated patients using autologous DCs transduced with an adenovirus encoding a truncated LMP1 (ΔLMP1) and full-length LMP2 (Ad-ΔLMP1-LMP2).

MATERIALS AND METHODS

Sixteen subjects with metastatic NPC received Ad-ΔLMP1-LMP2 DC vaccines i.d. biweekly for up to five doses. Toxicity, immune responses and clinical responses were determined.

RESULTS

Most patients had extensive disease, with a median of three visceral sites of involvement (range 1-7). No significant toxicity was observed. Ad-ΔLMP1-LMP2 DCs induced delayed type hypersensitivity responses in 9 out of 12 patients, but although these DCs activated LMP1/2-specific T cells in vitro, no such increase in the frequency of peripheral LMP1/2-specific T cells was detected. Three patients had clinical responses including one with partial response (for 7½ months) and two with stable disease (for 6½ and 7½ months).

CONCLUSIONS

Ad-ΔLMP1-LMP2 transduced DCs can be successfully generated and safely administered to patients with advanced NPC. Since efficacy was limited, future studies should focus on DC vaccines with greater potency administered to subjects with less tumor burden.

Graft-vs-tumor effect in patients with advanced nasopharyngeal cancer treated with nonmyeloablative allogeneic PBSC transplantation

While nonmyeloablative peripheral blood stem cell transplantation (NST) has shown efficacy against several solid tumors, it is untested in nasopharyngeal cancer (NPC). In a phase II clinical trial, 21 patients with pretreated metastatic NPC underwent NST with sibling PBSC allografts, using CY conditioning, thymic irradiation and in vivo T-cell depletion with thymoglobulin. Stable lymphohematopoietic chimerism was achieved in most patients and prophylactic CYA was tapered at a median of day +30. Seven patients (33%) showed partial response and three (14%) achieved stable disease. Four patients were alive at 2 years and three showed prolonged disease control of 344, 525 and 550 days. With a median follow-up of 209 (4-1147) days, the median PFS was 100 days (95% confidence interval (CI), 66-128 days), and median OS was 209 days (95% CI, 128-236 days). Patients with chronic GVHD had better survival-median OS 426 days (95% CI, 194-NE days) vs 143 days (95% CI, 114-226 days) (P=0.010). Thus, NST may induce meaningful clinical responses in patients with advanced NPC.

A phase I pharmacokinetic study of a liposomal formulation of paclitaxel administered weekly to Asian patients with solid malignancies

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Background: Genexol-PM is a sterile, lyophilized polymeric micellar formulation of paclitaxel which is devoid of Cremophor EL and hence is more tolerable and less toxic. This phase 1 study sought to determine the maximum tolerated dose and the pharmacokinetic profile of Genexol-PM in Asian cancer patients with solid malignancies. Methods: Patients (N=35) refractory to previous chemotherapy were enrolled in a phase 1, open-label, dose-escalating study to assess safety, tolerability ad pharmacokinetics of Genexol-PM administered as a 1h infusion on a weekly basis for 3 weeks followed by a resting week. The starting dose was 80mg/m2. Cohorts of 1–6 patients were treated at 100, 120, 140, 160, 180 and the maximum administered dose was 200 mg/m2. Results: The median age was 56 years (range: 39 - 67 years) and two thirds of the enrolled patients were male (67%). Twenty-three patients (96%) had received prior chemotherapy, including eleven patients (46%) who had previously received taxane-based chemotherapy. The majority of patients had lung, nasopharyngeal and breast cancers. DLT was reached at 200 mg/m2. The MTD was 180 mg/m2. Grade 3 granulocytopenia was common in patients receiving Genexol-PM at doses of 120 mg/m2 or higher in the first cycle. The most common grade 3 non-haematologic adverse events in cycle 1 were fatigue, myalgia and neuropathy and occurred mainly at dose level 7 (200 mg/m2) in 4%, 4% and 8% of the patients. Five (21%) patients had partial response, 9 (38%) had stable disease and seven (29%) patients had disease progression. The pharmacokinetics of Genexol-PM displayed dose-proportionality, with both Cmax and AUC0-∞ values increasing by approximately 4- and 3-fold as the dose of Genexol-PM was increased from 80mg/m2 to 200mg/m2 with no significant change in clearance. The median total-body clearance of Genexol-PM for all patients was 43.9 L/hr. Conclusions: The weekly regimen of Genexol-PM was found to be well-tolerated and responses were observed in patients with refractory tumours, including patients who had failed taxane-based chemotherapy previously.

No significant financial relationships to disclose.

Global Lung Oncology Branch trial 3 (GLOB3): final results of a randomised multinational phase III study alternating oral and i.v. vinorelbine plus cisplatin versus docetaxel plus cisplatin as first-line treatment of advanced non-small-cell lung cancer

BACKGROUND

The study compared the efficacy of a first-line treatment with day 1 i.v. vinorelbine (NVBiv) and day 8 oral vinorelbine (NVBo) versus docetaxel (DCT) in a cisplatin-based combination in advanced non-small-cell lung cancer, in terms of time to treatment failure (TTF), overall response, progression-free survival (PFS), overall survival (OS), tolerance and quality of life (QoL).

METHODS

Patients were randomly assigned to receive cisplatin 80 mg/m2 with NVBiv 30 mg/m2 on day 1 and NVBo 80 mg/m2 on day 8 every 3 weeks, after a first cycle of NVBiv 25 mg/m2 on day 1 and NVBo 60 mg/m2 on day 8 (arm A) or cisplatin 75 mg/m2 and DCT 75 mg/m2 on day 1 every 3 weeks (arm B), for a maximum of six cycles in both arms.

RESULTS

From 2 February 2004 to 1 January 2006, 390 patients were entered in a randomised study and 381 were treated. The patient characteristics are as follows (arms A/B): metastatic (%) 80.5/84.8; patients with three or more organs involved (%) 45.3/40.8; median age 59.4/62.1 years; male 139/146; squamous (%) 34.2/33.5; adenocarcinoma (%) 41.6/39.3; median TTF (arms A/B in months) [95% confidence interval (CI)]: 3.2 (3.0-4.2), 4.1 (3.4-4.5) (P = 0.19); overall response (arms A/B) (95% CI): 27.4% (21.2% to 34.2%), 27.2% (21.0% to 34.2%); median PFS (arms A/B in months) (95% CI): 4.9 (4.4-5.9), 5.1 (4.3-6.1) (P = 0.99) and median OS (arms A/B in months) (95% CI): 9.9 (8.4-11.6), 9.8 (8.8-11.5) (P = 0.58). The median survival for squamous histology was 8.87/9.82 months and for adenocarcinoma 11.73/11.60 months for arms A and B, respectively. Main haematological toxicity was grade 3-4 neutropenia: 24.4% (arm A) and 28.8% (arm B). QoL as measured by the Lung Cancer Symptom Scale was similar in both arms.

CONCLUSIONS

Both arms provided similar efficacy in terms of response, time-related parameters and QoL, with an acceptable tolerance profile. In the current Global Lung Oncology Branch trial 3, NVBo was shown to be effective as a substitute for the i.v. formulation. This can relieve the burden of the i.v. injection on day 8 and can optimise the hospital's resources and improve patient convenience.

High incidence of symptomatic methemoglobinemia (metHb) in Asian patients (pts) treated with 3-Aminopyridine-2-carboxaldehyde thiosemicarbazone (3-AP, triapine) and gemcitabine (GEM) in a second-line phase II trial of metastatic non-small cell lung cancer

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Background: Triapine (Vion Pharmaceuticals) is an inhibitor of ribonucleotide reductase that can enhance GEM uptake in GEM- resistant cell lines. Clinically significant metHb has been rarely reported with triapine & G6PD-deficient pts maybe more susceptible. This multicenter study evaluated the activity & safety of combined triapine-GEM in pts with metastatic NSCLC who had progressed despite prior response or disease stabilization to 1st line platinum-GEM regimen. Methods: Eligible pts were treated with triapine (105mg/m2) as 4-hr IV infusion, followed by GEM (1g/m2) over 30-min on days 1, 8 & 15, repeating every 28 days for 6 cycles. G6PD-deficient pts were excluded. Results: 6 males & 6 female Asian pts (median age: 65 yrs) received a median no. of 2 cycles (range 1–6 cycles). At a median follow-up of 4.6 mos, no response was seen. 4 pts had stable disease. Median time to progression was 3 mos (95% CI: 1.7–9.1 mos). Gr 3–4 toxicities included neutropenia (gr 3, 2 pts), hypoxia (gr 3, 3 pts) & dyspnea (gr 3, 1 pt). There were no treatment-related deaths & all pts remained alive at analysis. 4 pts developed symptomatic metHb during, or ≤ 4 hrs of stopping triapine. This was manifested as dyspnea &/or hypoxia, associated with an oxygen saturation of ≤90% at room air. Arterial metHb assay performed during the hypoxic episode showed a metHb level of up to 15% of total concentration of hemoglobin ([Hb]), which fell to < 5% of [Hb] within 4–6 hrs of stopping triapine. All pts recovered with conservative treatment & none required reversal with methylene blue. 3 out of the 4 pts were able to continue treatment after dose-reduction of triapine. Conclusions: The cause of the relatively high incidence of triapine-related symptomatic metHb was unclear in this Asian cohort. This study was terminated prematurely due to lack of response.

No significant financial relationships to disclose.

Nonmyeloablative allogeneic blood stem cell transplantation (NMBSCT) ± donor lymphocyte infusion (DLI) for chemorefractory advanced nasopharyngeal carcinoma (NPC)

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Background: There is emerging clinical evidence for T cell immunotherapy in NPC. We report a NMBSCT regimen that induced mixed chimerism for DLI to potentially achieve a graft-versus-tumour effect (GVT) in NPC. Methods: 15 patients with advanced pretreated NPC were accrued to this prospective clinical trial. Our regimen comprised IV cyclophosphamide 50 mg/kg on day-5,-4,-3 and IV thymoglobuline on day-1, +1, +2 and +3 (n = 9) and then revised to IV thymoglobuline day-1, +1, +2, +3 (n = 6). Thymic radiation was given on day-1. G-CSF mobilized HLA-matched (n = 14) and 1-antigen-mismatched (n = 1) sibling PBSC were infused. DLI was initiated following taper of prophylactic cyclosporine (CyA). Results: Median age (n =15) was 49 yrs, median no. of metastatic organ sites was 3, mean no. of prior chemotherapy was 4 (range 2 - 8) and 14/15 had prior radiation. Median time to engraftment was 13 days and hospital stay was 17 days. Complete removal of prophylactic CyA was achieved for all patients at a median of day +28. DLI was given in 14 patients (median = 2, range 1 to 6). 4 patients were later re-started on GVHD immunosuppressive therapy. Two (13.3%) patients had acute GVHD (one Grade II and one fatal case who died on day+91). 3 patients developed chronic GVHD (20%), all controlled with short courses of standard immunosuppressive treatment. 11/15 died of PD, and 2/15 died from sepsis. 100-day TRM was 6.6%. 3/9 patients had donor graft loss. 6/6 patients on the revised protocol had stable and/or full donor chimerism. CMV antigenemia was 9/9 for the first regimen and 3/6 for the revised regimen (p = 0.044). Tumor response (RECIST) confirmed 40% PR, 33.3% SD and 40% PD, for a disease control rate of 73.3%. > day+100 anti-tumor response were observed in 5/15 patients (33.3%), implicating a GVT effect. 1 patient achieved a delayed PR on day+111 with stable donor chimerism of 19%. The longest surviving patient (36.5 mths) with multiple nodal, bone and lung metastasis achieved full donor chimerism and further tumor shrinkage at 8 mths post-NMBSCT. Conclusions: GVT is achievable with NMBSCT ± DLI in Stage IV NPC patients with a high disease control rate and acceptable GVHD. Early complete removal of prophylactic CyA was possible in all 15 patients.

No significant financial relationships to disclose.

Phase II Trial of Gemcitabine and Cisplatin Sequentially Administered in Asian Patients With Unresectable or Metastatic Non-small Cell Lung Cancer

Introduction: The aim of this study was to assess toxicity and response in the sequential administration of gemcitabine followed by cisplatin in unresectable or metastatic non-small cell lung cancer. Materials and Methods: Twenty-three patients were enrolled in this study. Gemcitabine was given at 1250 mg/m2 on days 1 and 8, for four 21-day cycles, followed by cisplatin 40 mg/m2 on days 1, 8 and 15, for three further 28-day cycles. Results: There were 4 patients with partial responses, 5 patients with stable disease and 10 patients with progressive disease, giving a response rate of 21%. The median time to disease progression was 3.3 months. The median overall survival was 14.6 months. Toxicities graded 3 or 4 included anaemia (13.0%), neutropaenia (13.0%), supraventricular tachycardia (4.3%), and nausea and vomiting (4.3%). Conclusion: Although these results show similar efficacy to single-agent treatment regimens, the low toxicity profile and promising survival outcome with this regimen are important points for consideration. Key words: Anaemia, Neutropaenia, Supraventricular tachycardia

Phase II trial of gemcitabine and cisplatin sequentially administered in Asian patients with unresectable or metastatic non-small cell lung cancer

INTRODUCTION

The aim of this study was to assess toxicity and response in the sequential administration of gemcitabine followed by cisplatin in unresectable or metastatic non-small cell lung cancer.

MATERIALS AND METHODS

Twenty-three patients were enrolled in this study. Gemcitabine was given at 1,250 mg/m2 on days 1 and 8, for four 21-day cycles.

RESULTS

There were 4 patients with partial responses. 5 patients with stable disease and 10 patients with progressive disease, giving a response rate of 21%. The median time to disease progression was 3.3 months. The median overall survival was 14.6 months. Toxicities graded 3 or 4 included anaemia (13.0%), neutropaenia (13.0%), supraventricular tachycardia (4.3%), and nausea and vomiting (4.3%).

CONCLUSION

Although these results show similar efficacy to single-agent treatment regimens, the low toxicity profile and promising survival outcome with this regimen are important points for consideration.

Randomized study of vinorelbine--gemcitabine versus vinorelbine--carboplatin in patients with advanced non-small cell lung cancer

PURPOSE

The objective of this trial was to compare two vinorelbine-based doublets with carboplatin (CBDCA-VC) or with gemcitabine (VG) in patients with stage IIIB-IV non-small cell lung cancer (NSCLC).

PATIENTS AND METHODS

A total of 316 patients with advanced NSCLC previously untreated were randomized to either vinorelbine 30 mg/m(2) D1,8 with carboplatin AUC 5 D1 (VC) or vinorelbine 25mg/m(2) with gemcitabine (VG) 1000 mg/m(2) both given D1,8 every 3 weeks. The primary endpoint was response rate with secondary parameters being survival (OS), progression-free survival (PFS), tolerance and clinical benefit.

RESULTS

The median number of cycles was four in each arm with a total of 1268 cycles. The objective response (OR) on intent-to-treat was 20.8% in VC and 28% in VG (p=0.15). Median PFS was 3.9 months in VC and 4.4 months (mo) in VG (p=0.18). Median survival was significantly longer (p=0.01) for VG with 11.5 mo compared to 8.6 mo in VC with 1 year survival at 48.9 and 34.4%, respectively. Tolerance was better in the VG arm as compared to the VC patients. Four toxic deaths were recorded in the VC group. Clinical benefit response rate was 32.4% compared to 40.9% in 111 and 110 evaluable patients in VC and VG, respectively.

CONCLUSION

VG compared to VC resulted in a similar overall response rate, favourable median survival and a better toxicity profile. For non-cisplatin-based chemotherapy, VG is a useful alternative.

Concurrent chemoradiotherapy followed by surgery in locally advanced squamous cell carcinoma of the oesophagus: a single centre experience

INTRODUCTION

Data on combined modality treatment for locally advanced squamous cell carcinoma of the oesophagus involving Asian patients are limited.

MATERIALS AND METHODS

A retrospective study of 56 consecutive patients with this condition treated with concurrent chemoradiotherapy followed by surgery in a single tertiary institution in Singapore was performed.

RESULTS

The median overall survival of the entire cohort was 14.1 months [95% confidence interval (CI); range, 8.6 to 19.6 months]. In patients who underwent successful oesophagectomy after chemoradiotherapy (n = 17), the median survival was 27.8 months compared to 9.8 months for those who did not have surgery (n = 39) (P = 0.046, log-rank test). The median time to first relapse for the entire cohort was 16.1 months (95% CI, 7.7 to 24.5 months). The time to first relapse was 23.9 months in the subgroup of patients with successful surgery and 12.1 months in the group which did not (P = 0.147, log-rank test). The high proportion of patients who were medically unfit for surgery or declined surgery may have conferred a selection bias.

CONCLUSION

Concurrent chemoradiotherapy followed by surgery is feasible in selected patients. The benefit of adding of surgery to chemoradiotherapy is still controversial and we await the results of randomised controlled trials comparing chemoradiotherapy with surgery versus chemoradiotherapy alone.