European clinical practice guidelines on the use of chemotherapy for advanced oesophageal and gastric cancers: a critical review using the AGREE II and the AGREE-REX instruments

Utilising systematic reviews to assess potential overtreatment and claim for better evidence-based research: an analysis of anticancer drugs versus supportive care in advanced esophageal cancer

BACKGROUND

Highlighting the identified gaps in evidence-based research concerning advanced esophageal cancer (EC) treatment and care, this review evaluates the efficacy and safety of anticancer drugs compared to supportive care for advanced EC patients, aiming to assess the appropriateness of usual treatments and identify the gaps that need to be filled with primary research.

METHODS

We searched (May 2022) MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), Epistemonikos, and trial registries (ClinicalTrials.gov and PROSPERO) for randomised controlled trials (RCTs) comparing anticancer drugs (chemotherapy, immunotherapy, or biological/targeted therapy) with supportive care in advanced EC. The results were summarised using GRADE summary of finding tables.

RESULTS

We included 15 RCTs. Most studies did not have a special focus on EC, did not detail the treatment lines in all patients, and did not evaluate all outcomes. Anticancer drugs may result in a slight increase in overall survival (OS) (HR 0.78; 95% CI 0.71, 0.86; MD 0.83 months) and better progression-free survival (PFS) (HR 0.56 95% CI 0.49, 0.64, MD 0.68 months), but also may increase toxicity (RR 1.37; 95% CI 1.13, 1.65), without a significant improvement in quality of life. The certainty of evidence was low or very low due to indirectness of results and lack of specific focus on EC in some studies.

CONCLUSION

RCTs on advanced EC lack specificity, detailed treatment line information, and evaluation of all relevant outcomes. Moreover, when they find any benefit, this is negligible. Therefore, the certainty to justify anticancer drug treatments instead of supportive care in advanced EC is low or very low, and this information should be actively shared with affected patients. More and better RCTs should be conducted to assess whether any old or new proposed treatment for advanced EC patients provides a better balance of benefits and harms than the supportive care.

SYSTEMATIC REVIEW REGISTRATION

The study protocol was registered in OSF ( https://doi.org/10.17605/OSF.IO/7CHX6 ) on 2022-03-29.

Methodological quality and clinical recommendations of guidelines on the management of dyslipidaemias for cardiovascular disease risk reduction: a systematic review and an appraisal through AGREE II and AGREE REX tools

BACKGROUND

Clinical practice guidelines (CPGs) are statements to assist practitioners and stakeholders in decisions about healthcare. Low methodological quality guidelines may prejudice decision-making and negatively affect clinical outcomes in non-communicable diseases, such as cardiovascular diseases worsted by poor lipid management. We appraised the quality of CPGs on dyslipidemia management and synthesized the most updated pharmacological recommendations.

METHODS

A systematic review following international recommendations was performed. Searches to retrieve CPG on pharmacological treatments in adults with dyslipidaemia were conducted in PubMed, Scopus, and Trip databases. Eligible articles were assessed using AGREE II (methodological quality) and AGREE-REX (recommendation excellence) tools. Descriptive statistics were used to summarize data. The most updated guidelines (published after 2019) had their recommendations qualitatively synthesized in an exploratory analysis.

RESULTS

Overall, 66 guidelines authored by professional societies (75%) and targeting clinicians as primary users were selected. The AGREE II domains Scope and Purpose (89%) and Clarity of Presentation (97%), and the AGREE-REX item Clinical Applicability (77.0%) obtained the highest values. Conversely, guidelines were methodologically poorly performed/documented (46%) and scarcely provided data on the implementability of practical recommendations (38%). Recommendations on pharmacological treatments are overall similar, with slight differences concerning the use of supplements and the availability of drugs.

CONCLUSION

High-quality dyslipidaemia CPG, especially outside North America and Europe, and strictly addressing evidence synthesis, appraisal, and recommendations are needed, especially to guide primary care decisions. CPG developers should consider stakeholders' values and preferences and adapt existing statements to individual populations and healthcare systems to ensure successful implementation interventions.

How appropriate is treating patients diagnosed with advanced esophageal cancer with anticancer drugs? A multicenter retrospective cohort Spanish study

AIM

To assess the appropriateness of systemic oncological treatments (SOT) provided to patients diagnosed with advanced esophageal cancer (EC) across a group of participating hospitals.

METHODS

Multicenter, retrospective cohort study in five Spanish hospitals including newly confirmed advanced EC cases between July 1, 2014, and June 30, 2016, with a 5-year follow-up.

RESULTS

We identified 157 patients fulfilling the inclusion criteria (median age: 65 years, 85.9% males). Most patients, 125 (79.6%) were treated at least with one active treatment, and 33% received two or more lines of SOT. The 1-, 2- and 5-year overall survival rates were 30.3% [95%CI: 23.8, 38.7], 14.0% [95%CI: 9.3, 21.0], and 7.1% [95% CI: 3.8, 13.1] respectively, and the median survival time 8 months (95% CI: 6, 19) for stages IIIb IIIc and 7 months (95% CI: 5, 9) for stage IV. Clinical stage, receiving more than one line of SOT, and treatment with radiotherapy accelerated the time to death (0.4, 0.9-, and 0.8-times shorter survival respectively, p < 0.05). Better performance status (ECOG < 2) extended survival time by 2.2 times (p = 0.04). Age < 65 years (OR 9.4, 95% CI 3.2, 31.4, p < 0.001), and being treated in one particular hospital (OR 0.2, 95% CI 0.0, 0.8, p < 0.01) were associated with the administration of two or more lines of SOT. Altogether, 18.9% and 9.0% of patients received chemotherapy in the last four and two weeks of life, respectively. Moreover, 2.5% of patients were prescribed a new line of chemotherapy during the last month of life. The proportion of all patients who did not have access to palliative care reached 29.3%, and among those who had access to it, 34.2% initiated it in the last month of life.

CONCLUSION

A high proportion of advanced EC patients receive many treatments not based on sound evidence and they do not benefit enough from palliative care services. The most accepted appropriateness indicators point out that some of the analyzed patients could have been overtreated. This study provides important insights into the quality of care provided to advanced EC, and furthermore, for giving valuable insight and opportunities for improvement.

Assessing the methodological strengths and limitations of the Spanish Society of Medical Oncology (SEOM) guidelines: a critical appraisal using AGREE II and AGREE-REX tool

BACKGROUND

The Spanish Society of Medical Oncology (SEOM) has provided open-access guidelines for cancer since 2014. However, no independent assessment of their quality has been conducted to date. This study aimed to critically evaluate the quality of SEOM guidelines on cancer treatment.

METHODS

Appraisal of Guidelines for Research and Evaluation II (AGREE II) and AGREE-REX tool was used to evaluate the qualities of the guidelines.

RESULTS

We assessed 33 guidelines, with 84.8% rated as "high quality". The highest median standardized scores (96.3) were observed in the domain "clarity of presentation", whereas "applicability" was distinctively low (31.4), with only one guideline scoring above 60%. SEOM guidelines did not include the views and preferences of the target population, nor did specify updating methods.

CONCLUSIONS

Although developed with acceptable methodological rigor, SEOM guidelines could be improved in the future, particularly in terms of clinical applicability and patient perspectives.

Treatments for non-small cell lung cancer: a systematic quality assessment of clinical practice guidelines

AIM

To evaluate the methodological quality of clinical practice guidelines (CPGs) on treatments for non-small cell lung cancer (NSCLC).

METHODS

We searched MEDLINE, CPG developer websites, lung cancer societies, and oncology organizations to identify CPGs providing recommendations on treatments for NSCLC. The methodological quality for each CPG was determined independently by three appraisers using the AGREE II (Appraisal of Guidelines for Research and Evaluation II) instrument.

RESULTS

Twenty-two CPGs met the eligibility criteria. The median scores per AGREE II domain were: scope and purpose 90.7% (64.8-100%), stakeholder involvement 76.9% (27.8-96.3%); rigor of development 80.9% (27.1-92.4%); clarity of presentation 89.8% (50-100%); applicability 46.5% (12.5-87.5%); and editorial independence 91.7% (27.8-100%). Most of the CPGs (54.5%) were rated as "recommended with modifications" for clinical use.

CONCLUSIONS

Overall, the methodological quality of CPGs proving recommendations on the management of NSCLC is moderate, but there is still room for improvement in their development and implementation.

Polyphyllin I suppresses the gastric cancer growth by promoting cancer cell ferroptosis

Background: Ferroptosis is a new form of regulated cell death characterized by the accumulation of iron-dependent lipid peroxides and membrane damages. Recent studies have identified an important role for cancer cell ferroptosis in antitumor therapy. On the other hand, polyphyllin I (PPI) has been reported to exert antitumor effects on some types of cancers. However, it remains unknown whether or not PPI regulates cancer cell ferroptosis.

Methods: Two types of human gastric cancer cells (AGS and MKN-45) were used to establish tumor xenograft models in nude mice that were treated with polyphyllin I (PPI) to observe tumor growth, while cells also were cultured for in vitro studies. Ferroptosis, based on the intracellular ROS/lipid ROS production and accumulation of ferrous ions, was detected using a fluorescence microscope and flow cytometer, while the expression of NRF2/FTH1 was measured using Western blotting assays.

Results: Here we found that PPI inhibited the gastric cancer growth in vivo and in vitro while increasing the intracellular reactive oxygen species (ROS)/lipid peroxides and ferrous ions in the gastric cancer cells. PPI also decreased the levels of nuclear factor erythroid 2-related factor 2 (NRF2) and ferritin heavy chain 1 (FTH1) in gastric cancer cells in vitro. Moreover, liproxstain-1, an inhibitor of cell ferroptosis, mostly reversed the cell ferroptosis and tumor growth arrest induced by PPI. Finally, the effects of PPI on cancer cell ferroptosis were diminished by the overexpression of NRF2.

Conclusion: For the first time, our results have demonstrated that PPI exerts its antitumor activity on the gastric cancer by, at least partially, inducing cancer cell ferroptosis via regulating NRF2/FTH1 pathway. These findings may be implicated for clinical replacement therapy of the gastric cancer.

Chinese herbal medicine and COVID-19: quality evaluation of clinical guidelines and expert consensus and analysis of key recommendations

To systematically review the clinical practice guidelines (CPGs) for the treatment of patients with coronavirus disease 2019 (COVID-19) using Chinese herbal medicine (CHM), assess the methodological quality as well as clinical credibility and implementability of specific recommendations, and summarize key recommendations.

Methods

As of April 2022, we conducted a comprehensive search on major electronic databases, guideline websites, academic society websites, and government websites to assess the methodological quality and clinical applicability of the included CPGs using the Appraisal of Guidelines for Research and Evaluation (AGREE) II tool and Evaluation-Recommendations EXcellence (AGREE-REX) instructions, respectively.

Results

The search yielded 61 CPGs, which were mostly published in 2020; moreover, 98.4% of the CPGs were published in China. Only five CPGs achieved a high-quality AGREE II rating; further, six CPGs could be directly recommended, with most of the CPGs still showing much room for improvement. CPGs had a low overall score in the AGREE-REX evaluation, with the domains of clinical applicability, values and preferences, and implementability being standardized in 21.80% ± 12.56%, 16.00% ± 11.81%, and 31.33% ± 14.55% of the CPGs, respectively. Five high-quality CPGs mentioned 56 Chinese herbal formulas. Half of the recommendations had moderate or strong evidence level in the GRADE evaluation. The most frequently recommended herbal medicines were Lianhua Qingwen granule/capsule and Jinhua Qinggan granule; however, the strength of recommendation for each prescription varied across CPGs and populations.

Conclusions

The overall quality of current CPGs for COVID-19 for CHM still needs to be improved; moreover, the strength of the evidence remains to be standardized across CPGs.

Graphical abstract

http://links.lww.com/AHM/A34.

European clinical practice guidelines on the use of chemotherapy for advanced oesophageal and gastric cancers: a critical review using the AGREE II and the AGREE-REX instruments

PURPOSE

To assess the methodological quality of all relevant and recent European clinical practice guidelines (CPGs) for advanced oesophageal and gastric cancers, and to synthesise their recommendations on the use of chemotherapy.

METHODS

We searched PubMed, EMBASE, guidelines repositories, and other sources from 2010 onwards. We appraised quality using AGREE-II and AGREE-REX.

RESULTS

11 CPGs were included (five high, five low, and one moderate quality). Most guidelines showed deficiencies in the domain "applicability", with only three scoring above 60%. Nine did not report having sought the views and preferences of the target population. The lowest scores for AGREE-REX were item Values and Preferences of Target Users (1.6; SD 1.3), and item Values and Preferences of Policy/Decision-Makers (1.8; SD 1.7). The domain Clinical Applicability got the highest score and the domain Implementability got the lowest.

CONCLUSIONS

An urgent area of research is how to develop credible and implementable recommendations on the clinical use of CT for advanced oesophageal and gastric cancer.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO (CRD42021236753).