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Introduction
Complete surgical eradication of cancer:
Surgery
release cancer cells into the
circulation
depresses cell mediated immunity
reduces circulating concentrations
of tumor related antiangiogenic
factors
increases concentrations of proangiogenic factors
releases growth factors that
promote local and distant growth
of malignant tissue
Anesthesia
- Impairs many immune
function
Opioids
- Inhibit cellular and
humoral immune function
in humans
- pro-angiogenic and
promotes growth of
breast
tumours in rodents
Introduction
Regional anesthesia and analgesia:
- prevents the neuroendocrine stress response to surgery by
blocking afferent neural transmission from reaching the CNS and
by blocking descending efferent activation of the sympathetic
nervous system volatile anesthetics and sparing
postoperative opioids
- release of endogenous opioids
- opioid induced immune impairment
In animals reduce the metastatic burden in animals inoculated
with breast adenocarcinoma cells
In humans
two reported beneficial effects in breast cancer and prostate
cancer
three reported no beneficial effects in colon cancer, prostate
cancer, and cervical cancer
one equivocal results in prostate cancer
METHODS
This is an follow up study of MASTER trial
MASTER was a multicentre randomised clinical
trial designed to test the hypothesis that
combined epidural and general anesthesia
reduces the frequency of a composite end point
of mortality and major postoperative
complications compared with general
anasthesia and opioid analgesia
METHODS
Study design and participants
Design : Long term follow-up of prospective randomised
controlled clinical trial in which patients were randomly
assigned to receive general anesthesia with or without
epidural block for at least three postoperative days
Participants : 503 adult patients who had potentially
curative surgery for cancer (complete surgical excision
of cancer) esophagectomy, gastrectomy,
hepatectomy, pancreatectomy, colectomy,
nephrectomy, cystectomy, radical hysterectomy,
and open prostatectomy
Setting : 23 hospitals in Australia, New Zealand, and
Asia
METHODS
Study Profile
METHODS
Follow up data : the patients medical record from
the source hospital, hospital surgery or pathology
databases (or both), the patient s general
practitioner, state based cancer registry or national
death index (or both), letter of introduction followed
by telephone contact of the patient, and letter of
introduction followed by telephone contact of the
patient s next of kin
Cause of death : cancer, cardiovascular disease,
sepsis, and other causes
METHODS
Study end points:
primary end point of the study : cancer-free survival after
surgery
the secondary endpoint : survival (all cause mortality)
Statistical analysis:
Intention to treat principle
Kaplan Meier survival estimates and log-rank test
Outcomes of cancer (five year survival and five year
disease-free survival) 2 test and multivariate logistic
model
SPSS for Windows, version 18 for analyses
RESULT
RESULT
RESULT
RESULT
RESULT
RESULT
RESULT
DISCUSSION
DISCUSSION
Other studies:
Benefit:
Exadaktylos AK, Buggy DJ, Moriarty DC, Mascha E, Sessler DI.
Can anesthetic technique for primary breast cancer surgery
affect recurrence or metastasis?
Biki B, Mascha E, Moriarty DC, Fitzpatrick JM, Sessler DI, Buggy
DJ Anesthetic technique for radical prostatectomy surgery
affects
cancer recurrence: a retrospective analysis.
No benefit:
Gottschalk A, et al. Association between epidural analgesia and
cancer recurrence after colorectal cancer surgery.
Tsui BC, Rashiq et al. Epidural anesthesia and cancer
recurrence rates after radical prostatectomy.
Ismail H, Ho KM, Narayan K, Kondalsamy-Chennakesavan S.
Effect of neuraxial anaesthesia on tumour progression in
cervical cancer patients treated with brachytherapy: a
retrospective cohort study
DISCUSSION
Strength:
compared its 9-15 years outcomes in a relatively large group of patients
who were randomly assigned to general anesthesia combined with
epidural anesthesia and analgesia versus general anesthesia and opioid
analgesia
well powered to detect a one third treatment effect but lacked power to
reliably detect smaller effects that might still be of considerable clinical
importance, particularly for individual types of cancer
Limitation
This study does not provide information on the effects of regional blockade
on non-abdominal (for example, breast) cancers.
CONCLUSION
Even though this study could not identify
any reduction in recurrence of cancer or
survival when epidural block was used for
surgery for abdominal cancer, it doesnt
meant that Regional analgesia (especially
epidural block) is an inferior choice
because it still provide a good post
operative pain treatment, can limit opioid
related side effects and reduce the risk of
hypotension.
CRITICAL APPRAISAL
CLINICAL QUESTION
Can regional anesthesia reduce the
risk of recurrence in patient
undergoing cancer surgery compared
to general anesthesia?
PICO
PICO Clinical Question
Journal
Patient undergoing
cancer surgery
Regional anesthesia
GA
GA
risk of recurrence
Telaah Validitas
Jawaban Sesuai
Worksheet
Recruitment
Ya.
Penelitian ini adalah
follow up dari
MASTER trial
mewakili pasien
dimasukkan dalam
penelitian pada waktu
perjalanan
penyakitnya
sama?
Telaah Validitas
Jawaban Sesuai
Worksheet
Allocation
Bagaimana pasien
Ya.
diperlakukan? Jika
ada subkelompok
dengan prognosis
berbeda, apakah
dilakukan
penyesuaian untuk
faktor prognosis yang
penting?
Telaah Validitas
Jawaban Sesuai
Worksheet
Maintenance
Apakah status
kelompok
dipertahankan tetap
sebanding dengan
manajemen yang
sama? dan follow up
yang memadai?
Ya
Telaah Validitas
Jawaban Sesuai
Worksheet
Measurement
Blinding
Outcome
Ya.
Ya
Tidak.
Ya.
Ya.
Ya.
Ya.
Ya.