Cochrane Review: abstract/plain text summary - Centralisation of services for gynaecological cancer - The Cochrane Library - Woo - Wiley Online Library

Centralisation of services for gynaecological cancer - The Cochrane Library 

Authors' conclusions

We found low quality, but consistent evidence to suggest that women with gynaecological cancer who received treatment in specialised centres had longer survival than those managed elsewhere. The evidence was stronger for ovarian cancer than for other gynaecological cancers.
Further studies of survival are needed, with more robust designs than retrospective observational studies. Research should also assess the quality of life associated with centralisation of gynaecological cancer care. Most of the available evidence addresses ovarian cancer in developed countries; future studies should be extended to other gynaecological cancers within different healthcare systems.

 

Plain language summary

Gynaecological cancers are cancers affecting the ovaries, uterus, cervix, vulva, and vagina.  They are the second most common cancers among women, after breast cancer. It is often suggested that outcomes are improved by centralising care within highly specialised services that include expert surgeons, radiologists, pathologists, oncologists who specialise in chemotherapy and radiotherapy, specialist nurses and other health professionals. However, consensus is lacking on whether centralisation of care for gynaecological cancer helps patients to live longer. This review investigated this issue by comparing the survival of women diagnosed with gynaecological cancer who received care from specialised and unspecialised centres.

We used a set of tests to ensure that the evidence the five studies identified reached the quality standard for our analysis.The analysis of three studies combined (meta-analysis), assessing over 9000 women, suggested that institutions with gynaecologic oncologists (specialists in the field of gynaecological cancer treatment) on site may prolong the lives of women with ovarian cancer compared to community or general hospitals. Similarly, another meta-analysis of three studies which assessed well over 50,000 women, found evidence to suggest that teaching centres or regional cancer centres (specialised centres) (Blogger's Note: do the specialized/regional centre have gynecologic oncologists/clinical trial access....) may prolong the lives of women with gynaecological cancer compared to community or general hospitals. The largest study in this meta-analysis assessed all gynaecological cancers in 48,981 women, so it had major influence on the final result; this means that our findings are likely to be relevant to other gynaecological cancers, besides ovarian cancer.

Overall, the findings suggest that centralisation of care may prolong the lives of women with gynaecological cancer, and in particular ovarian cancer. However, the results should be interpreted with caution as all of the studies included in the review could be biased. For example, it is possible that the patients who were treated in specialised centres were less ill to begin with. Another weakness of the review is that only one of the studies included women with gynaecological cancers other than ovarian cancer. (Blogger's opinion: any studies of this nature should differentiate and isolate/categorize the gynecologic cancers as treatments, side effects, survival rates, genetics....vary greatly)

Ideally, further studies in this area are needed.  New studies should be designed to avoid the possibility of bias due to the treatment of women at specialist and non-specialist centres being systematically different.

Additionally, studies should assess the impact of centralisation of care on the quality of life of patients.

Most of the available evidence was about ovarian cancer in developed countries; future studies should be extended to other gynaecological cancers and to less developed countries.

Antioxidant supplements for prevention of mortality in healthy participants and patients with various diseases - The Cochrane Library ((beta-carotene, vitamin A, vitamin C, vitamin E, and selenium)

Antioxidant supplements for prevention of mortality in healthy participants and patients with various diseases - The Cochrane Library

 Abstract

"The increased risk of mortality was associated with beta-carotene and possibly vitamin E and vitamin A, but was not associated with the use of vitamin C or selenium. The current evidence does not support the use of antioxidant supplements in the general population or in patients with various diseases."

Background

Our systematic review has demonstrated that antioxidant supplements may increase mortality. We have now updated this review.

Objectives

To assess the beneficial and harmful effects of antioxidant supplements for prevention of mortality in adults.

Cochrane Review: Adjuvant (post-surgery) chemotherapy for early stage epithelial ovarian cancer (abstract)

Adjuvant (post-surgery) chemotherapy for early stage epithelial ovarian cancer [Cochrane Database Syst Rev. 2012]

Cochrane Database Syst Rev. 2012 Mar 14;3:CD004706.

Adjuvant (post-surgery) chemotherapy for early stage epithelial ovarian cancer.

Abstract

BACKGROUND:

Epithelial ovarian cancer is diagnosed in 4500 women in the UK each year of whom 1700 will ultimately die of their disease.Of all cases 10% to 15% are diagnosed early when there is still a good possibility of cure. The treatment of early stage disease involves surgery to remove disease often followed by chemotherapy. The largest clinical trials of this adjuvant therapy show an overall survival (OS) advantage with adjuvant platinum-based chemotherapy but the precise role of this treatment in subgroups of women with differing prognoses needs to be defined.

OBJECTIVES:

To systematically review the evidence for adjuvant chemotherapy in early stage epithelial ovarian cancer to determine firstly whether there is a survival advantage of this treatment over the policy of observation following surgery with chemotherapy reserved for treatment of disease recurrence, and secondly to determine if clinical subgroups of differing prognosis based on histological sub-type, or completeness of surgical staging, have more or less to gain from chemotherapy following initial surgery.

SELECTION CRITERIA:

We selected randomised clinical trials that met the inclusion criteria set out based on the populations, interventions, comparisons and outcome measures.

MAIN RESULTS:

Five randomised controlled trials (RCTs), enrolling 1277 women, with a median follow-up of 46 to 121 months, met the inclusion criteria. Four trials were included in the meta-analyses and we considered them to be at a low risk of bias. Meta-analysis of five-year data from three trials indicated that women who received adjuvant platinum-based chemotherapy had better overall survival (OS) than those who did not (1008 women; hazard ratio (HR) 0.71; 95% confidence interval (CI) 0.53 to 0.93). Likewise, meta-analysis of five-year data from four trials indicated that women who received adjuvant chemotherapy had better progression-free survival (PFS) than those who did not (1170 women; HR 0.67; 95% CI 0.53 to 0.84). The trials included in these meta-analyses gave consistent estimates of the effects of chemotherapy. In addition, these findings were robust over time (10-year PFS: two trials, 925 women; HR 0.67; 95% CI 0.54 to 0.84).
Subgroup analysis suggested that women who had optimal surgical staging of their disease were unlikely to benefit from adjuvant chemotherapy (HR for OS 1.22; 95% CI 0.63 to 2.37; two trials, 234 women) whereas those who had sub-optimal staging did (HR for OS 0.63; 95% CI 0.46 to 0.85; two trials, 772 women). One trial showed a benefit from adjuvant chemotherapy among women at high risk (HR for OS 0.48; 95% CI 0.32 to 0.72) but not among those at low/medium risk (HR for OS 0.95; 95% CI 0.54 to 1.66).
However, these subgroup findings could be due to chance and should be interpreted with caution.

AUTHORS' CONCLUSIONS:

Adjuvant platinum-based chemotherapy is effective in prolonging the survival of the majority of patients who are assessed as having early (FIGO stage I/IIa) epithelial ovarian cancer. However, it may be withheld from women in whom there is well-differentiated encapsulated unilateral disease (stage 1a grade 1) or those with comprehensively staged Ib, well or moderately differentiated (grade 1/2) disease. Others with unstaged early disease or those with poorly differentiated tumours should be offered chemotherapy.

A pragmatic approach may be necessary in clinical settings where optimal staging is not normally performed/achieved. In such settings, adjuvant chemotherapy may be withheld from those with encapsulated stage Ia grade 1 serous and endometrioid carcinoma and offered to all others with early stage disease.

Cochrane Review - Medscape article: Specialized Care May Boost Cancer Survival - in Oncology/Hematology, Ovarian Cancer

Medical News:Specialized Care May Boost Cancer Survival - in Oncology/Hematology, Ovarian Cancer

Wiley: Cochrane Review - Specialist cancer care may improve patient outcomes (ovarian/gyn cancers)

Wiley: Specialist cancer care may improve patient outcomes

The Cochrane Library

 More Press Releases related to this journal

Vol 2012 (4 Issues in 2012)

Specialist cancer care may improve patient outcomes

Survival rates for cancer patients may be improved by treatment in specialised cancer centres, according to Cochrane researchers. In a review of recent studies, they found that women diagnosed with gynaecological cancer lived longer when treated in specialist compared to non-specialist units.
In the past, cancer patients were often treated by non-specialist surgeons and hospitals. This is changing and in developed countries, most cancer care is now organised into networks of specialised centres, with on-site experts and specialised nursing staff. This centralised approach, although costly, may help improve outcomes for patients.
The review focused on data from five studies, altogether involving more than 62,000 women who were treated from the late 1990s onwards. Over 48,000 of the participants were involved in one study carried out in 2009, whilst the smallest study involved just 250. Due to clinical differences between the studies, the researchers combined the data in different ways. Incorporating three studies and over 50,000 women with gynaecological cancer, one analysis showed that women treated at teaching centres or regional cancer centres lived longer compared to those treated at community or general hospitals. An alternative combination of three of the studies, involving over 9,000 women with ovarian cancer, showed that those treated at institutions with on-site gynaecologists lived longer compared to those treated at community or general hospitals.
“We found consistent evidence for specialist treatment prolonging survival rates in women with gynaecological cancer,” said lead researcher, Professor Yin Ling Woo of the University of Malaya Cancer Research Institute, University of Malaya, in Kuala Lumpur, Malaysia. “The effect seemed to be strongest for ovarian cancer, although most evidence came from developed countries.”
The researchers estimate that survival rates could be improved by around 10%, although uncertainties in the data mean the actual figure could range between 1% and 18%. Better designed studies are needed to confirm the results. All five studies included in the review used electronic records to identify patients after they had received treatment, meaning it was difficult to be sure that the centralised and de-centralised treatment groups were similar.
“Ideally, women should be allocated to specialist and non-specialist treatment groups in advance to ensure that there is no bias in the data,” said Professor Woo. “These higher quality trials are needed to assess whether the extra cost is worthwhile, especially as many countries have limited resources for specialist care.”

Interferon after surgery for women with advanced (Stage II-IV) epithelial ovarian cancer - The Cochrane Library - Lawal - Wiley Online Library

Abstract

This is the protocol for a review and there is no abstract. The objectives are as follows:

To assess the effectiveness and safety of interferon after surgery in the treatment of advanced (stage II-IV) epithelial ovarian cancer.

abstract - EvidenceUpdates: Cochrane Review: Primary prophylaxis for venous thromboembolism in ambulatory cancer patients receiving chemotherapy (including professional commentaries)

Abstract

BACKGROUND:  Venous thromboembolism (VTE) often complicates the clinical course of cancer disease. The risk is further increased by chemotherapy but the safety and efficacy of primary thromboprophylaxis in cancer patients treated with chemotherapy is uncertain. OBJECTIVES:  To assess the efficacy and safety of primary thromboprophylaxis in ambulatory cancer patients receiving chemotherapy.  AUTHORS' CONCLUSIONS:   Primary thromboprophylaxis with LMWH significantly reduced the incidence of symptomatic VTE in ambulatory cancer patients treated with chemotherapy. However, the lack of power hampers definite conclusions on the effects on major safety outcomes, which mandates additional studies to determine the risk to benefit ratio of LMWH in this setting.

Comments from Clinical Raters
Oncology - Breast

Antigen-specific active immunotherapy for ovarian cancer

              " " Information on adverse events was frequently limited."

PLAIN LANGUAGE SUMMARY:


Epithelial ovarian cancer is the most frequently diagnosed ovarian malignancy and the leading cause of death from gynaecological cancers. Standard therapy consists of surgery followed by chemotherapy. Although initial response rates are high, the majority of patients with advanced disease relapse. No curative treatment is available for recurrent disease. The observation that the presence of certain immune cells in tumours is associated with improved survival, suggests that stimulation of anti-tumour immune responses, i.e. immunotherapy, might be a useful approach to improve prognosis of ovarian cancer. In this review, the feasibility of antigen-specific active immunotherapy is evaluated. Antigen-specific active immunotherapy aims at the induction of tumour-directed immune responses through the administration of a tumour-antigen, a molecule that is preferentially expressed by tumour cells and can induce immune responses. As immunotherapy is a novel (new) treatment strategy early phase studies were also included. Information on clinical and immunological responses, and adverse events was collected.

Thirty-six studies, which included 1780 ovarian cancer patients, were identified between 1966 and 2009. The most frequently described strategy (1505 patients in 15 studies) was administration of antibodies targeting CA-125. Most of these primarily evaluated safety and immunological responses. Five studies described severe flu-like and gastro-intestinal symptoms in 7 to 30% of patients. Antibodies and immune cells recognising CA-125 were frequently detected, albeit response rates varied between studies. Despite promising immunological responses, three large studies found equal survival rates for patients treated with placebo or CA-125 directed antibody. Because there is currently no high quality evidence of clinical benefit, antibody therapy targeting CA-125 should in its current form not be incorporated in standard treatment.

For strategies not relying on antibody administration, similar conclusions cannot be drawn as these have not yet been tested in large trials to evaluate clinical efficacy of treatment. These were generally small studies primarily investigating vaccine safety and immunogenicity. Overall, treatment was well-tolerated, with inflammatory side effects at injection site most frequently reported. Antibodies and immune cells were induced by most strategies studied, but their clinically efficacy still has to be evaluated in large trials.

Based on a lack of uniformity in included studies, we strongly advocate universal adoption of response definitions, guidelines for adverse events reporting, and directives for trial conduct and reporting. Furthermore, results from ongoing RCTs should be awaited and furhter RCTs should be conducted.

ABSTRACT:

Objectives

To assess feasibility of antigen-specific active immunotherapy for ovarian cancer. Primary outcomes are clinical efficacy and antigen-specific immunogenicity with carrier-specific immunogenicity and side-effects as secondary outcomes.