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Gupta KK, De M, Athanasiou T, Georgalas C, Garas G. Quality of life outcomes comparing primary Transoral Robotic Surgery (TORS) with primary radiotherapy for early-stage oropharyngeal squamous cell carcinoma: A systematic review and meta-analysis. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2024; 50:108434. [PMID: 38795678 DOI: 10.1016/j.ejso.2024.108434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2024] [Revised: 05/09/2024] [Accepted: 05/20/2024] [Indexed: 05/28/2024]
Abstract
BACKGROUND Transoral Robotic Surgery (TORS) and radiotherapy are considered oncologically equivalent primary treatment options for early-stage HPV-positive oropharyngeal squamous cell carcinoma (OPSCC). Quality of Life (QoL) and Patient Reported Outcome Measures (PROMs) are therefore imperative in supporting clinical decision-making and optimising patient-centred care. The aim of this article is to evaluate how these primary treatment modalities compare in terms of QoL. MATERIALS AND METHODS Systematic review and meta-analysis of studies comparing primary TORS and primary radiotherapy for OPSCC using validated QoL tools. Swallowing and global QoL were the primary endpoints with secondary endpoints including all other QoL domains. An inverse variance random-effects model was employed to calculate the weighted estimate of the treatment effects across trials. RESULTS A total of six studies collectively reporting on 555 patients were included (n = 236 TORS and n = 319 radiotherapy). Meta-analysis showed no significant difference for swallowing (mean difference = -0.24, p = 0.89) and global QoL (mean difference = 4.55, p = 0.14). For the remaining QoL domains (neck/shoulder impairment, neurotoxicity, voice, xerostomia, speech, and distress), the scarcity of data did not permit meta-analysis. However, the existing data showed no significant difference for any except for xerostomia where TORS appears favourable in the sole study reporting on this. CONCLUSIONS TORS and radiotherapy appear to be comparable primary treatment options for early stage OPSCC when it comes to QoL. However, a substantial proportion of patients in the TORS group received adjuvant (chemo)radiotherapy rendering it difficult to establish the 'true' QoL outcomes following surgery alone. There are also minimal studies reporting QoL outcomes beyond swallowing and global QoL. Further research is therefore needed, including more randomised trials adequately powered to detect differences in QoL outcomes.
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Affiliation(s)
- Keshav Kumar Gupta
- Head & Neck Unit. Department of Otorhinolaryngology and Head & Neck Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom.
| | - Mriganka De
- Head & Neck Unit. Department of Otorhinolaryngology and Head & Neck Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Thanos Athanasiou
- Department of Surgery & Cancer, Imperial College London, St. Mary's Hospital, London, United Kingdom
| | - Christos Georgalas
- Endoscopic Skull Base Centre Athens, Hygeia Hospital, Athens, Greece; Medical School, University of Nicosia, Nicosia, Cyprus
| | - George Garas
- Head & Neck Unit. Department of Otorhinolaryngology and Head & Neck Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom; Department of Surgery & Cancer, Imperial College London, St. Mary's Hospital, London, United Kingdom
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Heinz P, Wendel-Garcia PD, Held U. Impact of the matching algorithm on the treatment effect estimate: A neutral comparison study. Biom J 2024; 66:e2100292. [PMID: 35385172 DOI: 10.1002/bimj.202100292] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2021] [Revised: 02/22/2022] [Accepted: 02/25/2022] [Indexed: 11/12/2022]
Abstract
Propensity score matching is increasingly being used in the medical literature. Choice of matching algorithms, reporting quality, and estimands are oftentimes not discussed. We evaluated the impact of propensity score matching algorithms, based on a recent clinical dataset, with three commonly used outcomes. The resulting estimands for different strengths of treatment effects were compared in a neutral comparison study and based on a thoroughly designed simulation study. Different algorithms yielded different levels of balance after matching. Along with full matching and genetic matching with replacement, good balance was achieved with nearest neighbor matching with caliper but thereby more than one fifth of the treated units were discarded. Average marginal treatment effect estimates were least biased with genetic or nearest neighbor matching, both with replacement and full matching. Double adjustment yielded conditional treatment effects that were closer to the true values, throughout. The choice of the matching algorithm had an impact on covariate balance after matching as well as treatment effect estimates. In comparison, genetic matching with replacement yielded better covariate balance than all other matching algorithms. A literature review in the British Medical Journal including its subjournals revealed frequent use of propensity score matching; however, the use of different matching algorithms before treatment effect estimation was only reported in one out of 21 studies. Propensity score matching is a methodology for causal treatment effect estimation from observational data; however, the methodological difficulties and low reporting quality in applied medical research need to be addressed.
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Affiliation(s)
- Priska Heinz
- Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics, University of Zurich, Zurich, Switzerland
| | | | - Ulrike Held
- Epidemiology, Biostatistics and Prevention Institute, Department of Biostatistics, University of Zurich, Zurich, Switzerland
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3
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Goldkuhle M, Guyatt GH, Kreuzberger N, Akl EA, Dahm P, van Dalen EC, Hemkens LG, Klugar M, Mustafa RA, Nonino F, Schünemann HJ, Trivella M, Skoetz N. GRADE concept 4: rating the certainty of evidence when study interventions or comparators differ from PICO targets. J Clin Epidemiol 2023; 159:40-48. [PMID: 37146659 DOI: 10.1016/j.jclinepi.2023.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2023] [Revised: 04/13/2023] [Accepted: 04/26/2023] [Indexed: 05/07/2023]
Abstract
OBJECTIVES This Grading of Recommendations Assessment, Development and Evaluation (GRADE) concept article offers systematic reviewers, guideline authors, and other users of evidence assistance in addressing randomized trial situations in which interventions or comparators differ from those in the target people, interventions, comparators, and outcomes. To clarify what GRADE considers under indirectness of interventions and comparators, we focus on a particular example: when comparator arm participants receive some or all aspects of the intervention management strategy (treatment switching). STUDY DESIGN AND SETTING An interdisciplinary panel of the GRADE working group members developed this concept article through an iterative review of examples in multiple teleconferences, small group sessions, and e-mail correspondence. After presentation at a GRADE working group meeting in November 2022, attendees approved the final concept paper, which we support with examples from systematic reviews and individual trials. RESULTS In the presence of safeguards against risk of bias, trials provide unbiased estimates of the effect of an intervention on the people as enrolled, the interventions as implemented, the comparators as implemented, and the outcomes as measured. Within the GRADE framework, differences in the people, interventions, comparators, and outcomes elements between the review or guideline recommendation targets and the trials as implemented constitute issues of indirectness. The intervention or comparator group management strategy as implemented, when it differs from the target comparator, constitutes one potential source of indirectness: Indirectness of interventions and comparators-comparator group receipt of the intervention constitutes a specific subcategory of said indirectness. The proportion of comparator arm participants that received the intervention and the apparent magnitude of effect bear on whether one should rate down, and if one does, to what extent. CONCLUSION Treatment switching and other differences between review or guideline recommendation target interventions and comparators vs. interventions and comparators as implemented in otherwise relevant trials are best considered issues of indirectness.
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Affiliation(s)
- Marius Goldkuhle
- Evidence-based Medicine, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany.
| | - Gordon H Guyatt
- Department of Health Research Methods, Evidence, and Impact, Michael G DeGroote Cochrane Canada Centre, Cochrane Canada, McMaster GRADE Centre and Department of Medicine, McMaster University, 1280 Main St. W., Hamilton, ON L8S 4K1, Canada
| | - Nina Kreuzberger
- Evidence-based Medicine, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
| | - Elie A Akl
- Department of Internal Medicine, American University of Beirut, Lebanon, P.O.Box 11-0236 and Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St. W., Hamilton, ON L8S 4K1, Canada
| | - Philipp Dahm
- Minneapolis VA Health Care System, Urology Section 112D, One Veterans Drive, Minneapolis, Minnesota 55417
| | - Elvira C van Dalen
- Princess Máxima Center for Pediatric Oncology, Heidelberglaan 25, 3584CS Utrecht, the Netherlands
| | - Lars G Hemkens
- Department of Clinical Research, University Hospital Basel, University of Basel, Basel, Switzerland; Research Center for Clinical Neuroimmunology and Neuroscience Basel (RC2NB), University Hospital Basel and University of Basel, Basel, Switzerland; Meta-Research Innovation Center at Stanford (METRICS), Stanford University, Stanford, CA, USA; Meta-Research Innovation Center Berlin (METRIC-B), Berlin Institute of Health, Berlin, Germany
| | - Miloslav Klugar
- Czech National Centre for Evidence-Based Healthcare and Knowledge Translation (Cochrane Czech Republic, Czech EBHC: JBI Centre of Excellence, Masaryk University GRADE Centre), Faculty of Medicine, Masaryk University, 625 00 Brno, Czech Republic; Institute of Health Information and Statistics of the Czech Republic, 100 00 Prague, Czech Republic
| | - Reem A Mustafa
- Department of Medicine and Population Health, University of Kansas Health System, 3901 Rainbow Blvd, MS3002, Kansas City, KS 66160, USA; Department of Health Research Methods, Evidence, and Impact, McMaster University, 1280 Main St. W., Hamilton, Ontario L8S 4K1, Canada
| | - Francesco Nonino
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Unit of Epidemiology and Statistics, Cochrane Review Group Multiple Sclerosis and Rare Diseases of the CNS, Via Altura 3, 40139 Bologna, Italy
| | - Holger J Schünemann
- Department of Health Research Methods, Evidence, and Impact, Michael G DeGroote Cochrane Canada Centre, Cochrane Canada and McMaster GRADE Centre, McMaster University, Hamilton, Ontario, Canada; Department of Medicine, McMaster University, Hamilton, Ontario, Canada; Department of Biomedical Sciences, Humanitas University, Milan, Italy; Cochrane Canada, Hamilton, Ontario, Canada
| | - Marialene Trivella
- Department of Cardiovascular Medicine, John Radcliffe Hospital, University of Oxford, UK; Department of Population Health, London School of Hygiene and Tropical Medicine, London
| | - Nicole Skoetz
- Evidence-based Medicine, Department I of Internal Medicine, Faculty of Medicine and University Hospital Cologne, University of Cologne, Kerpener Str. 62, 50937 Cologne, Germany
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Garas G, Roland NJ, Lancaster J, Zammit M, Manon VA, Davies K, Jones TM, De M, Holsinger FC, Prestwich RJD, Fleming JC. Novel Strategies for Managing Retropharyngeal Lymph Node Metastases in Head and Neck and Thyroid Cancer with Transoral Robotic Surgery (TORS). Ann Surg Oncol 2022; 29:7881-7890. [PMID: 35842533 DOI: 10.1245/s10434-022-12208-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2022] [Accepted: 07/01/2022] [Indexed: 12/18/2022]
Abstract
Retropharyngeal metastases are encountered in a variety of head and neck malignancies, imposing significant surgical challenges owing to their distinct location and proximity to neurovascular structures. Radiotherapy is the recommended treatment in most cases owing to its oncological efficacy. However, retropharyngeal irradiation affects the superior pharyngeal constrictor muscles and parotid glands, with the potential for long-term dysphagia and xerostomia. A younger oropharyngeal and thyroid cancer patient demographic is trending, fueling interest in treatment de-escalation strategies. Consequently, reducing radiotoxicity and its long-term effects is of special relevance in modern head and neck oncology practice. Through its unique ability to safely extirpate these traditionally difficult-to-access retropharyngeal lymph nodes via a natural orifice, TransOral Robotic Surgery (TORS) can considerably lower the surgical morbidity of retropharyngeal lymph node dissection (RPLND), compared with current existing approaches. This review summarizes the latest developments in the field, exposing current research gaps and discusses specific clinical settings where TORS could enable treatment de-escalation. In early-stage node-negative oropharyngeal cancer, single-modality surgical treatment with TORS RPLND may improve risk stratification of metastasis and recurrence in this region. TORS RPLND is also a potentially viable treatment option in salvage of an isolated retropharyngeal node recurrence or in the primary setting of a thyroid malignancy with a single positive retropharyngeal node. In time, TORS RPLND may provide an alternative de-escalation strategy in these three scenarios. However, with the reported morbidities, further prospective trials with long-term follow-up data are required to prove oncological safety and functional benefits over existing strategies.
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Affiliation(s)
- George Garas
- Head and Neck Unit, Department of Otorhinolaryngology and Head and Neck Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham, UK.
| | - Nick J Roland
- Liverpool Head and Neck Centre, Department of Otorhinolaryngology and Head & Neck Surgery, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Jeffrey Lancaster
- Liverpool Head and Neck Centre, Department of Otorhinolaryngology and Head & Neck Surgery, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Matthew Zammit
- Liverpool Head and Neck Centre, Department of Otorhinolaryngology and Head & Neck Surgery, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Victoria A Manon
- Department of Oral and Maxillofacial Surgery, The University of Texas at Houston, Houston, TX, USA
| | - Katharine Davies
- Liverpool Head and Neck Centre, Department of Otorhinolaryngology and Head & Neck Surgery, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Terry M Jones
- Liverpool Head and Neck Centre, Department of Otorhinolaryngology and Head & Neck Surgery, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
| | - Mriganka De
- Head and Neck Unit, Department of Otorhinolaryngology and Head and Neck Surgery, Queen Elizabeth Hospital Birmingham, University Hospitals Birmingham NHS Foundation Trust, Mindelsohn Way, Edgbaston, Birmingham, UK
| | - Floyd C Holsinger
- Department of Otorhinolaryngology and Head and Neck Surgery, Stanford School of Medicine, Stanford, CA, USA
| | - Robin J D Prestwich
- Department of Clinical Oncology, Leeds Cancer Centre, The Leeds Teaching Hospitals NHS Trust, Leeds, UK
| | - Jason C Fleming
- Liverpool Head and Neck Centre, Department of Otorhinolaryngology and Head & Neck Surgery, Aintree University Hospital, Liverpool University Hospitals NHS Foundation Trust, Liverpool, UK
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Comment on "Synthetic Versus Biological Mesh in Laparoscopic and Open Ventral Hernia Repair (LAPSIS) by Miserez et al. Published in January 2021". Ann Surg 2021; 274:e908-e909. [PMID: 34784673 DOI: 10.1097/sla.0000000000004934] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Lee S, Sardar H, Horner NS, Al Mana L, Miller BS, Khan M, Alolabi B. Subscapularis-sparing approaches in shoulder arthroplasty: A systematic review. J Orthop 2021; 24:165-172. [PMID: 33716422 DOI: 10.1016/j.jor.2021.02.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Revised: 01/18/2021] [Accepted: 02/21/2021] [Indexed: 11/15/2022] Open
Abstract
Background Novel approaches for anatomic and reverse total shoulder arthroplasty (aTSA and rTSA) that spare the subscapularis (SSC) have recently been described. Outcomes for the SSC-sparing approach were evaluated through this systematic review. Methods Medline, Embase, PubMed, and CENTRAL were searched. Results From 2051 citations, 8 studies were included (aTSA group, n = 241; rTSA group, n = 68). SSC-sparing aTSA and rTSA were associated with significant postoperative improvements in shoulder function and range of motion at 12- to 24-month follow-up. Conclusion The SSC-sparing approach may provide a safe alternative for up to two years post-surgery. Evidence for long-term use remains inconclusive.
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Affiliation(s)
- Sandra Lee
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University; Hamilton, Ontario, Canada
| | - Huda Sardar
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University; Hamilton, Ontario, Canada
| | - Nolan S Horner
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University; Hamilton, Ontario, Canada
| | - Latifah Al Mana
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University; Hamilton, Ontario, Canada
| | | | - Moin Khan
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University; Hamilton, Ontario, Canada
| | - Bashar Alolabi
- Division of Orthopaedic Surgery, Department of Surgery, McMaster University; Hamilton, Ontario, Canada
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Niburski K, Guadagno E, Mohtashami S, Poenaru D. Shared decision making in surgery: A scoping review of the literature. Health Expect 2020; 23:1241-1249. [PMID: 32700367 PMCID: PMC7696205 DOI: 10.1111/hex.13105] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2019] [Revised: 06/24/2020] [Accepted: 06/26/2020] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Shared decision making (SDM) has been increasingly implemented to improve health-care outcomes. Despite the mixed efficacy of SDM to provide better patient-guided care, its use in surgery has not been studied. The aim of this study was to systematically review SDM application in surgery. DESIGN The search strategy, developed with a medical librarian, included nine databases from inception until June 2019. After a 2-person title and abstract screen, full-text publications were analysed. Data collected included author, year, surgical discipline, location, study duration, type of decision aid, survey methodology and variable outcomes. Quantitative and qualitative cross-sectional studies, as well as RCTs, were included. RESULTS A total of 6060 studies were retrieved. A total of 148 were included in the final review. The majority of the studies were in plastic surgery, followed by general surgery and orthopaedics. The use of SDM decreased surgical intervention rate (12 of 22), decisional conflict (25 of 29), and decisional regret (5 of 5), and increased decisional satisfaction (17 of 21), knowledge (33 of 35), SDM preference (13 of 16), and physician trust (4 of 6). Time increase per patient encounter was inconclusive. Cross-sectional studies showed that patients prefer shared treatment and surgical treatment varied less. The results of SDM per type of decision aid vary in terms of their outcome. CONCLUSION SDM in surgery decreases decisional conflict, anxiety and surgical intervention rates, while increasing knowledge retained decisional satisfaction, quality and physician trust. Surgical patients also appear to prefer SDM paradigms. SDM appears beneficial in surgery and therefore worth promoting and expanding in use.
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Affiliation(s)
| | - Elena Guadagno
- Division of Pediatric General and Thoracic SurgeryThe Montreal Children’s HospitalMcGill University Health CentreMontrealQCCanada
| | - Sadaf Mohtashami
- Division of Pediatric General and Thoracic SurgeryThe Montreal Children’s HospitalMcGill University Health CentreMontrealQCCanada
| | - Dan Poenaru
- Division of Pediatric General and Thoracic SurgeryThe Montreal Children’s HospitalMcGill University Health CentreMontrealQCCanada
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Fernandes PRDEO, Fernandes Neto FA, Wohnrath DR, Vazquez VDEL. Caution is needed in interpreting the results of comparative studies regarding oncological operations by minimally invasive versus laparotomic access. Rev Col Bras Cir 2020; 47:e20202458. [PMID: 32578695 DOI: 10.1590/0100-6991e-20202458] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Accepted: 04/09/2020] [Indexed: 11/22/2022] Open
Abstract
We aim to alert the difference between groups while comparing studies of abdominal oncological operations performed either by minimally invasive or laparotomic approaches and potential conflicts of interest in presenting or interpreting the results. Considering the large volume of scientific articles that are published, there is a need to consider the quality of the scientific production that leads to clinical decision making. In this regards, it is important to take into account the choice of the surgical access route. Randomized, controlled clinical trials are the standard for comparing the effectiveness between these interventions. Although some studies indicate advantages in minimally invasive access, caution is needed when interpreting these findings. There is no detailed observation in each of the comparative study about the real limitations and potential indications for minimally invasive procedures, such as the indications for selected and less advanced cases, in less complex cavities, as well as its elective characteristic. Several abdominal oncological operations via laparotomy would not be plausible to be completely performed through a minimally invasive access. These cases should be carefully selected and excluded from the comparative group. The comparison should be carried out, in a balanced way, with a group that could also have undergone a minimally invasive access, avoiding bias in selecting those cases of minor complexity, placed in the minimally invasive group. It is not a question of criticizing the minimally invasive technologies, but of respecting the surgeon's clinical decision regarding the most convenient method, revalidating the well-performed traditional laparotomy route, which has been unfairly criticized or downplayed by many people.
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Affiliation(s)
| | | | - Durval Renato Wohnrath
- - Hospital de Amor de Barretos (Barretos Cancer Hospital - PIO XII Foundation), Surgery Oncology - Barretos - SP - Brazil
| | - VinÍcius DE Lima Vazquez
- - Hospital de Amor de Barretos (Barretos Cancer Hospital - PIO XII Foundation), Surgery Oncology - Barretos - SP - Brazil
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Zaina F, Di Felice F, Donzelli S, Negrini S. Symptomatic adult spinal deformity: implications for treatment and research. ANNALS OF TRANSLATIONAL MEDICINE 2020; 8:515. [PMID: 32395559 PMCID: PMC7210213 DOI: 10.21037/atm.2020.01.46] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Fabio Zaina
- ISICO (Italian Scientific Spine Institute), Milan, Italy
| | | | | | - Stefano Negrini
- Department of Biomedical, Surgical and Dental Sciences, University of Milan "La Statale", Milan, Italy.,IRCCS Istituto Ortopedico Galeazzi, Milan, Italy
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Gaudino M, Fremes SE, Ruel M, Di Franco A, Di Mauro M, Chikwe J, Frati G, Girardi LN, Taggart DP, Biondi-Zoccai G. Prevalence and Impact of Treatment Crossover in Cardiac Surgery Randomized Trials: A Meta-Epidemiologic Study. J Am Heart Assoc 2019; 8:e013711. [PMID: 31663420 PMCID: PMC6898839 DOI: 10.1161/jaha.119.013711] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Background Crossover dilutes treatment effect and reduces statistical power of intention-to-treat analysis. We examined incidence and impact on cardiac surgery randomized controlled trial (RCT) outcomes of crossover from experimental to control interventions, or vice versa. Methods and Results MEDLINE, EMBASE, and Cochrane Library were searched, and RCTs (≥100 patients) comparing ≥2 adult cardiac surgical interventions were included. Crossover from the initial treatment assignment and relative risks (RRs) for each trial's primary end point and mortality at longest available follow-up were extracted. All RRs were calculated as >1 favored control group and <1 favored experimental arm. Primary outcome was the effect estimate for primary end point of each RCT, and secondary outcome was all-cause mortality; both were appraised as RR at the longest follow-up available. Sixty articles reporting on 47 RCTs (25 440 patients) were identified. Median crossover rate from experimental to control group was 7.0% (first quartile, 2.0%; third quartile, 9.7%), whereas from control to experimental group, the rate was 1.3% (first quartile, 0%; third quartile, 3.6%). RRs for primary end point and mortality were higher in RCTs with higher crossover rate from experimental to control group (RR, 1.01 [95% CI, 0.94-1.07] versus RR, 0.80 [95% CI, 0.66-0.97] and RR, 1.02 [95% CI, 0.95-1.11] versus RR, 0.94 [95% CI, 0.82-1.07], respectively). Crossover from control to experimental group did not alter effect estimates for primary end point or mortality (RR, 0.82 [95% CI, 0.63-1.05] versus RR, 0.95 [95% CI, 0.86-1.04] and RR, 0.88 [95% CI, 0.73-1.07] versus RR, 1.02 [95% CI, 0.95-1.09], respectively). Conclusions Crossover from experimental to control group is associated with outcomes of cardiac surgery RCTs. Crossover should be minimized at designing stage and carefully appraised after study completion.
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Affiliation(s)
- Mario Gaudino
- Department of Cardiothoracic Surgery Weill Cornell Medicine New York NY
| | - Stephen E Fremes
- Schulich Heart Centre Division of Cardiac Surgery Department of Surgery Sunnybrook Health Sciences Centre University of Toronto Ontario Canada
| | - Marc Ruel
- University of Ottawa Heart Institute University of Ottawa Ontario Canada
| | | | | | - Joanna Chikwe
- Department of Cardiothoracic Surgery Stony Brook School of Medicine New York NY.,Department of Cardiothoracic Surgery Mount Sinai Hospital New York NY
| | - Giacomo Frati
- Department of Medico-Surgical Sciences and Biotechnologies Sapienza University of Rome Latina Italy.,Istituto di Ricovero e Cura a Carattere Scientifico (I.R.C.C.S.) Neuromed Pozzilli Italy
| | - Leonard N Girardi
- Department of Cardiothoracic Surgery Weill Cornell Medicine New York NY
| | - David P Taggart
- Nuffield Department of Surgical Sciences University of Oxford United Kingdom
| | - Giuseppe Biondi-Zoccai
- Department of Medico-Surgical Sciences and Biotechnologies Sapienza University of Rome Latina Italy.,Mediterranea Cardiocentro Napoli Italy
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Oncological Minimally Invasive Surgery. JOURNAL OF ONCOLOGY 2019; 2019:1903297. [PMID: 31636664 PMCID: PMC6766159 DOI: 10.1155/2019/1903297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 07/25/2019] [Indexed: 11/17/2022]
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12
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Hohenberger P, Bonvalot S, van Coevorden F, Rutkowski P, Stoeckle E, Olungu C, Litiere S, Wardelmann E, Gronchi A, Casali P. Quality of surgery and surgical reporting for patients with primary gastrointestinal stromal tumours participating in the EORTC STBSG 62024 adjuvant imatinib study. Eur J Cancer 2019; 120:47-53. [PMID: 31479947 DOI: 10.1016/j.ejca.2019.07.028] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2019] [Revised: 07/24/2019] [Accepted: 07/27/2019] [Indexed: 01/13/2023]
Abstract
BACKGROUND EORTC (European Organisation of Research and Treatment of Cancer) 62024 is a phase III randomised trial evaluating adjuvant imatinib in patients with gastrointestinal stromal tumours (GISTs) and no evidence of residual disease after surgery in 908 patients from 11 countries participated. As surgical treatment aspects (tumour rupture and incomplete resection) contribute to the risk of recurrence, the data of primary surgery were reviewed. METHODS The surgical record, local pathology report and a surgical questionnaire on details of the operation had to be completed when patients entered the study. Surgeons from 5 countries, covering 8 languages, reviewed the full set of data being available from 793 patients (87.3%). RESULTS A known GIST was the reason for surgery in only 58% of the cases, and 12% of the patients were treated as an emergency. The R0-resection rate was 87%. The extent of resection was local excision in 17%, segmental resection in 59%, full-organ resection in 11% and multivisceral resection in 11%, with lymphadenectomy performed in 24% of the patients. Shelling out of the tumour was performed in 9.7%, and the proportion of tumours removed in parts was higher in the endoscopy/laparoscopy group. The incidence of tumour rupture (representing M1) was 9%. The consistency between preoperative and intraoperative findings was 82%. The postoperative complication rate was 7.3%. CONCLUSION The standardisation of surgery in this study was inferior. Given the review data, 18% of the patients should not have participated in the trial. Quality of surgery and improperly reported intraoperative details might influence the trial results. A detailed surgical questionnaire filled out by the surgeon is mandatory before entering the patient in an adjuvant trial in GIST.
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Affiliation(s)
- Peter Hohenberger
- Division of Surgical Oncology & Thoracic Surgery, Mannheim University Medical Center, University of Heidelberg, Germany.
| | - Sylvie Bonvalot
- Department of Surgery, Department of Surgery, Institut Curie, PSL University, Paris, France
| | - Frits van Coevorden
- Department of Surgical Oncology, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Pjotr Rutkowski
- Department of Soft Tissue/Bone Sarcoma and Melanoma, Maria Sklodowska-Curie Memorial Center and Institute of Oncology, Roentgen Str 5, 02-781, Warsaw, Poland
| | - Eberhard Stoeckle
- Surgery Department, Institut Bergonie, 229 Cours de L'Argonne, 33000 Bordeaux, France
| | - Christine Olungu
- Department of Biostatistics, European Organization for Research and Treatment of Cancer, Brussels, Belgium
| | - Saskia Litiere
- Department of Biostatistics, European Organization for Research and Treatment of Cancer, Brussels, Belgium
| | - Eva Wardelmann
- Gerhard-Domagk-Institute of Pathology, University of Münster Medical Center, Münster, Germany
| | - Alessandro Gronchi
- Department of Surgery, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
| | - Paolo Casali
- Department of Medical Oncology, Fondazione IRCCS Istituto Nazionale Dei Tumori, Milan, Italy
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13
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Abdelhafeez A, Ortega-Laureano L, Murphy AJ, Davidoff AM, Fernandez-Pineda I, Sandoval JA. Minimally Invasive Surgery in Pediatric Surgical Oncology: Practice Evolution at a Contemporary Single-Center Institution and a Guideline Proposal for a Randomized Controlled Study. J Laparoendosc Adv Surg Tech A 2019; 29:1046-1051. [PMID: 31241404 DOI: 10.1089/lap.2018.0467] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Background: Despite the lack of randomized or controlled trials for minimally invasive surgery (MIS) in pediatric surgical oncology, the integration of MIS into the surgical practice of pediatric oncology has become increasingly popular. The aim of this study was to evaluate the implementation of MIS in a pediatric tertiary cancer center and compare present use of MIS to that in a previous analysis at our center. Methods: We retrospectively reviewed the medical records of patients with pediatric cancer treated with MIS at a single institution between 2000 and 2014. Results: A total of 252 MIS procedures were performed: 73 laparoscopic (29%) and 179 thoracoscopic (71%). MIS was used for diagnostic purposes in 59% (146 thoracoscopic and 34 laparoscopic) and the therapeutic resection in 24% (39 laparoscopic cases and 33 thoracoscopic cases). Conversion to an open procedure occurred in 18 tumor resections (6%) and in 22 diagnostic biopsies (7%), mostly due to technical challenges in identifying or mobilizing tumors. Complications occurred in seven tumor resections (2%) and included three pneumothoraces, two bleeding complications, one bowel injury, and one wound infection. Complications occurred in 10 diagnostic biopsies (3%), mostly pneumothoraces. No tumor upstaging or trocar site recurrences occurred (follow-up time, 1-15 years). Conclusions: Over the last decade, we demonstrate the evolution of MIS in the management of solid tumors in children. We encourage surgeons and oncologists to join the call to arms to establish prospective trials evaluating MIS in pediatric surgical oncology.
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Affiliation(s)
| | | | - Andrew J Murphy
- 1Department of Surgery, St. Jude Children's Research Hospital, Memphis, Tennessee
| | - Andrew M Davidoff
- 1Department of Surgery, St. Jude Children's Research Hospital, Memphis, Tennessee
| | | | - John A Sandoval
- 1Department of Surgery, St. Jude Children's Research Hospital, Memphis, Tennessee
- 2HSHS Medical Group Pediatric Surgery, St. John's Children's Hospital, Springfield, Illinois
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14
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Garas G. ASO Author Reflections: Induced Bias Due to Crossover Within Randomized Controlled Trials in Surgical Oncology. Ann Surg Oncol 2018; 25:3889-3890. [PMID: 30238245 PMCID: PMC6245102 DOI: 10.1245/s10434-018-6771-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2018] [Indexed: 11/20/2022]
Affiliation(s)
- George Garas
- Surgical Epidemiology Unit, Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital, London, UK. .,Department of Surgical Research and Innovation, The Royal College of Surgeons of England, London, UK.
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15
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Analyses of repeated failures in cancer therapy for solid tumors: poor tumor-selective drug delivery, low therapeutic efficacy and unsustainable costs. Clin Transl Med 2018. [PMID: 29541939 PMCID: PMC5852245 DOI: 10.1186/s40169-018-0185-6] [Citation(s) in RCA: 282] [Impact Index Per Article: 47.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
For over six decades reductionist approaches to cancer chemotherapies including recent immunotherapy for solid tumors produced outcome failure-rates of 90% (±5) according to governmental agencies and industry. Despite tremendous public and private funding and initial enthusiasm about missile-therapy for site-specific cancers, molecular targeting drugs for specific enzymes such as kinases or inhibitors of growth factor receptors, the outcomes are very bleak and disappointing. Major scientific reasons for repeated failures of such therapeutic approaches are attributed to reductionist approaches to research and infinite numbers of genetic mutations in chaotic molecular environment of solid tumors that are bases of drug development. Safety and efficacy of candidate drugs tested in test tubes or experimental tumor models of rats or mice are usually evaluated and approved by FDA. Cost-benefit ratios of such ‘targeted’ therapies are also far from ideal as compared with antibiotics half a century ago. Such alarming records of failure of clinical outcomes, the increased publicity for specific vaccines (e.g., HPV or flu) targeting young and old populations, along with increasing rise of cancer incidence and death created huge and unsustainable cost to the public around the globe. This article discusses a closer scientific assessment of current cancer therapeutics and vaccines. We also present future logical approaches to cancer research and therapy and vaccines.
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