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Spence J, Belley-Côté E, Lee SF, Bangdiwala S, Whitlock R, LeManach Y, Syed S, Lamy A, Jacobsohn E, MacIsaac S, Devereaux PJ, Connolly S. The role of randomized cluster crossover trials for comparative effectiveness testing in anesthesia: design of the Benzodiazepine-Free Cardiac Anesthesia for Reduction in Postoperative Delirium (B-Free) trial. Can J Anaesth 2018; 65:813-821. [PMID: 29671186 DOI: 10.1007/s12630-018-1130-2] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Revised: 02/28/2018] [Accepted: 03/03/2018] [Indexed: 11/30/2022] Open
Abstract
Increasingly, clinicians and researchers recognize that studies of interventions need to evaluate not only their therapeutic efficacy (i.e., the effect on an outcome in ideal, controlled settings) but also their real-world effectiveness in broad, unselected patient groups. Effectiveness trials inform clinical practice by comparing variations in therapeutic approaches that fall within the standard of care. In this article, we discuss the need for studies of comparative effectiveness in anesthesia and the limitations of individual patient randomized-controlled trials in determining comparative effectiveness. We introduce the concept of randomized cluster crossover trials as a means of answering questions of comparative effectiveness in anesthesia, using the design of the Benzodiazepine-Free Cardiac Anesthesia for Reduction in Postoperative Delirium (B-Free) trial (Clinicaltrials.gov identifier NCT03053869).
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Affiliation(s)
- Jessica Spence
- Departments of Anesthesia and Critical Care and Health Research Methods, Evidence, and Impact, Population Health Research Institute (PHRI), McMaster University, 2V9 - 1280 Main St. West, Hamilton, ON, L8S 4K1, Canada.
| | - Emilie Belley-Côté
- Departments of Anesthesia and Critical Care, Medicine (Cardiology), and Health Research Methods, Evidence, and Impact, Population Health Research Institute (PHRI), McMaster University, Hamilton, ON, Canada
| | - Shun Fu Lee
- Population Health Research Institute (PHRI), Hamilton, ON, Canada
| | | | - Richard Whitlock
- Departments of Surgery (Cardiac Surgery) and Health Research Methods, Evidence, and Impact, Population Health Research Institute (PHRI), McMaster University, Hamilton, ON, Canada
| | - Yannick LeManach
- Departments of Anesthesia and Critical Care and Health Research Methods, Evidence, and Impact, Population Health Research Institute (PHRI), McMaster University, 2V9 - 1280 Main St. West, Hamilton, ON, L8S 4K1, Canada
| | - Summer Syed
- Department of Anesthesia and Critical Care, McMaster University, Hamilton, ON, Canada
| | - Andre Lamy
- Departments of Surgery (Cardiac Surgery) and Health Research Methods, Evidence, and Impact, Population Health Research Institute (PHRI), McMaster University, Hamilton, ON, Canada
| | - Eric Jacobsohn
- Departments of Anesthesia and Internal Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Sarah MacIsaac
- Population Health Research Institute (PHRI), Hamilton, ON, Canada
| | - P J Devereaux
- Departments of Medicine (Cardiology) and Health Research Methods, Evidence, and Impact, Population Health Research Institute (PHRI), McMaster University, Hamilton, ON, Canada
| | - Stuart Connolly
- Department of Medicine (Cardiology), Population Health Research Institute (PHRI), McMaster University, Hamilton, ON, Canada
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Sanchez-Salcedo P, Berto J, de-Torres JP, Campo A, Alcaide AB, Bastarrika G, Pueyo JC, Villanueva A, Echeveste JI, Lozano MD, García-Velloso MJ, Seijo LM, García J, Torre W, Pajares MJ, Pío R, Montuenga LM, Zulueta JJ. Lung Cancer Screening: Fourteen Year Experience of the Pamplona Early Detection Program (P-IELCAP). ACTA ACUST UNITED AC 2015. [DOI: 10.1016/j.arbr.2015.02.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Cribado de cáncer de pulmón: catorce años de experiencia del Programa Internacional de Detección Precoz de Cáncer de Pulmón con TBDR de Pamplona (P-IELCAP). Arch Bronconeumol 2015; 51:169-76. [DOI: 10.1016/j.arbres.2014.09.019] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 08/25/2014] [Accepted: 09/10/2014] [Indexed: 12/17/2022]
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Hofman A, Darwish Murad S, van Duijn CM, Franco OH, Goedegebure A, Ikram MA, Klaver CCW, Nijsten TEC, Peeters RP, Stricker BHC, Tiemeier HW, Uitterlinden AG, Vernooij MW. The Rotterdam Study: 2014 objectives and design update. Eur J Epidemiol 2013; 28:889-926. [PMID: 24258680 DOI: 10.1007/s10654-013-9866-z] [Citation(s) in RCA: 259] [Impact Index Per Article: 23.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 11/08/2013] [Indexed: 02/06/2023]
Abstract
The Rotterdam Study is a prospective cohort study ongoing since 1990 in the city of Rotterdam in The Netherlands. The study targets cardiovascular, endocrine, hepatic, neurological, ophthalmic, psychiatric, dermatological, oncological, and respiratory diseases. As of 2008, 14,926 subjects aged 45 years or over comprise the Rotterdam Study cohort. The findings of the Rotterdam Study have been presented in over a 1,000 research articles and reports (see www.erasmus-epidemiology.nl/rotterdamstudy ). This article gives the rationale of the study and its design. It also presents a summary of the major findings and an update of the objectives and methods.
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Affiliation(s)
- Albert Hofman
- Department of Epidemiology, Erasmus Medical Center, PO Box 2040, 3000 CA, Rotterdam, The Netherlands,
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Abstract
BACKGROUND This is an updated version of the original review published in The Cochrane Library in 1999 and updated in 2004 and 2010. Population-based screening for lung cancer has not been adopted in the majority of countries. However it is not clear whether sputum examinations, chest radiography or newer methods such as computed tomography (CT) are effective in reducing mortality from lung cancer. OBJECTIVES To determine whether screening for lung cancer, using regular sputum examinations, chest radiography or CT scanning of the chest, reduces lung cancer mortality. SEARCH METHODS We searched electronic databases: the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2012, Issue 5), MEDLINE (1966 to 2012), PREMEDLINE and EMBASE (to 2012) and bibliographies. We handsearched the journal Lung Cancer (to 2000) and contacted experts in the field to identify published and unpublished trials. SELECTION CRITERIA Controlled trials of screening for lung cancer using sputum examinations, chest radiography or chest CT. DATA COLLECTION AND ANALYSIS We performed an intention-to-screen analysis. Where there was significant statistical heterogeneity, we reported risk ratios (RRs) using the random-effects model. For other outcomes we used the fixed-effect model. MAIN RESULTS We included nine trials in the review (eight randomised controlled studies and one controlled trial) with a total of 453,965 subjects. In one large study that included both smokers and non-smokers comparing annual chest x-ray screening with usual care there was no reduction in lung cancer mortality (RR 0.99, 95% CI 0.91 to 1.07). In a meta-analysis of studies comparing different frequencies of chest x-ray screening, frequent screening with chest x-rays was associated with an 11% relative increase in mortality from lung cancer compared with less frequent screening (RR 1.11, 95% CI 1.00 to 1.23); however several of the trials included in this meta-analysis had potential methodological weaknesses. We observed a non-statistically significant trend to reduced mortality from lung cancer when screening with chest x-ray and sputum cytology was compared with chest x-ray alone (RR 0.88, 95% CI 0.74 to 1.03). There was one large methodologically rigorous trial in high-risk smokers and ex-smokers (those aged 55 to 74 years with ≥ 30 pack-years of smoking and who quit ≤ 15 years prior to entry if ex-smokers) comparing annual low-dose CT screening with annual chest x-ray screening; in this study the relative risk of death from lung cancer was significantly reduced in the low-dose CT group (RR 0.80, 95% CI 0.70 to 0.92). AUTHORS' CONCLUSIONS The current evidence does not support screening for lung cancer with chest radiography or sputum cytology. Annual low-dose CT screening is associated with a reduction in lung cancer mortality in high-risk smokers but further data are required on the cost effectiveness of screening and the relative harms and benefits of screening across a range of different risk groups and settings.
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Affiliation(s)
- Renée Manser
- Department of Haematology and Medical Oncology, Peter MacCallum Cancer Institute, St Andrew's Place, East Melbourne 3002, Victoria, and Department of Respiratory Medicine, Royal Melbourne Hospital, Melbourne, Australia.
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Dominioni L, Poli A, Mantovani W, Pisani S, Rotolo N, Paolucci M, Sessa F, Conti V, D'Ambrosio V, Paddeu A, Imperatori A. Assessment of lung cancer mortality reduction after chest X-ray screening in smokers: a population-based cohort study in Varese, Italy. Lung Cancer 2013; 80:50-4. [PMID: 23294502 DOI: 10.1016/j.lungcan.2012.12.014] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2012] [Accepted: 12/10/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND The effectiveness of screening for lung cancer (LC) in smokers on a population level, as distinct from the special circumstances that may apply in a randomized trial of selected volunteers, has not been thoroughly investigated. Here we evaluate by the standardized mortality ratio (SMR) indicator the impact of a chest X-ray (CXR) screening programme carried out at community level on LC mortality in smokers. METHODS All smokers of >10 pack-years, of both genders, ages 45-75 years, resident in 50 communities of the Province of Varese, Italy, screening-eligible, in 1997 were invited by their National Health Service (NHS) general practitioner physicians to a nonrandomized programme of five annual CXR screenings. The entire invitation-to-screen cohort (n=5815 subjects) received NHS usual care, with the addition of CXR exams in volunteer participants (21% of invitees), and was observed through December 2006. To overcome participants' selection bias of LC mortality assessment, for the entire invitation-to-screen cohort we estimated the LC-specific SMR, based on the local reference population receiving the NHS usual care. RESULTS Over the 8-year period 1999-2006, a total of 172 cumulative LC deaths were observed in the invitation-to-screen cohort; 210 were expected based on the reference population. Each year in the invited cohort the observed LC deaths were fewer than expected. The cumulative LC SMR was 0.82 (95% CI, 0.67-0.99; p=0.048), suggesting that LC mortality was reduced by 18% with CXR screening. CONCLUSION Implementation of a CXR screening programme at community level was associated with a significant reduction of LC mortality in smokers.
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Affiliation(s)
- Lorenzo Dominioni
- Center for Thoracic Surgery, University of Insubria, Ospedale di Circolo, Varese, Italy.
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Goldwasser DL, Kimmel M. Small median tumor diameter at cure threshold (<20 mm) among aggressive non-small cell lung cancers in male smokers predicts both chest X-ray and CT screening outcomes in a novel simulation framework. Int J Cancer 2012; 132:189-97. [DOI: 10.1002/ijc.27599] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2011] [Accepted: 03/27/2012] [Indexed: 11/06/2022]
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Marcus PM, Bergstralh EJ, Kramer BS, Fontana R. The Mayo Lung Project lung cancer mortality findings are unlikely to be biased by a volunteer effect. Eur J Epidemiol 2011; 26:503-4. [DOI: 10.1007/s10654-011-9580-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2011] [Accepted: 04/05/2011] [Indexed: 11/30/2022]
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Shi L, Tian H, McCarthy WJ, Berman B, Wu S, Boer R. Exploring the uncertainties of early detection results: model-based interpretation of mayo lung project. BMC Cancer 2011; 11:92. [PMID: 21375784 PMCID: PMC3058105 DOI: 10.1186/1471-2407-11-92] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2010] [Accepted: 03/07/2011] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The Mayo Lung Project (MLP), a randomized controlled clinical trial of lung cancer screening conducted between 1971 and 1986 among male smokers aged 45 or above, demonstrated an increase in lung cancer survival since the time of diagnosis, but no reduction in lung cancer mortality. Whether this result necessarily indicates a lack of mortality benefit for screening remains controversial. A number of hypotheses have been proposed to explain the observed outcome, including over-diagnosis, screening sensitivity, and population heterogeneity (initial difference in lung cancer risks between the two trial arms). This study is intended to provide model-based testing for some of these important arguments. METHOD Using a micro-simulation model, the MISCAN-lung model, we explore the possible influence of screening sensitivity, systematic error, over-diagnosis and population heterogeneity. RESULTS Calibrating screening sensitivity, systematic error, or over-diagnosis does not noticeably improve the fit of the model, whereas calibrating population heterogeneity helps the model predict lung cancer incidence better. CONCLUSIONS Our conclusion is that the hypothesized imperfection in screening sensitivity, systematic error, and over-diagnosis do not in themselves explain the observed trial results. Model fit improvement achieved by accounting for population heterogeneity suggests a higher risk of cancer incidence in the intervention group as compared with the control group.
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Affiliation(s)
- Lu Shi
- Department of Health Services, 650 Charles E, Young Drive S, 61-253 CHS, Los Angeles, CA 90095, USA.
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