Transcript ACCANIMENTO TERAPEUTICO IN ONCOLOGIA: VERO O …

ACCANIMENTO TERAPEUTICO IN ONCOLOGIA:
VERO O FALSO PROBLEMA?
Appropriatezze ed evidenze
di beneficio clinico in chirurgia
Giampaolo Ugolini
Dip. di Chirurgia
Az. Osp. Policlinico S.Orsola Malpighi
CONGRESSO REGIONALE DELLA SICP EMILIA ROMAGNA
Reggio Emilia 18/04/2008
Filippo Brunelleschi
1377 - 1446
Franz Torek (1861–1938). First esophagectomy for cancer in 1913
Torek F. The operative treatment of carcinoma of the esophagus.
Ann Surg 1915;61:385
CASO CLINICO
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66 yo F diagnosed with breast
cancer in 1999: surg + CHT/XRT
2000 bone mets D3-D5:
XRT/CHT/spinal stabilization
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2002 multiple bone mets: CHT
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2/2003 lung mets: CHT
CASO CLINICO
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4/2003: anal abscess
LOW RECTAL CANCER
What to do?
Colostomy vs. APR
Is it worthwile?
Is it right?
Cost-effectiveness?
CASO CLINICO
4/2003: Abdominoperineal excision
9/2004: bilat. ureteral stenting
12/2004: Small bowel obstruction due
to peritoneal carcinomatosis: ex. lap. +
ileostomy
3/2005: exitus
Guidelines Have Done More Harm than Good,
Amerling R et al. Blood Purif 26:73-76, 2008
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Proliferation of practice guidelines
Uncertain impact on actual practice and
outcomes
They are unlikely to stimulate original
research
Many guidelines are obsolete by the time
they are published
? Conflict of interest
Guidelines Have Done More Harm than Good,
Amerling R et al. Blood Purif 26:73-76, 2008
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A 'one-size-fits-all' approach is likely to
benefit some, but not all
Guidelines do not encourage clinicians
to consider and treat each patient as
an individual
Certain patients may be harmed by
adherence to specific guidelines
“Variability is the law of life, and as no
two faces are the same, so no two
bodies are alike, and no two
individuals react alike and behave alike
under abnormal conditions wich we
know as disease”
“Gentlemen, if you want a profession in
which everything is certain you had
better give up medicine!”
William Osler, 1926
Palliative cancer surgery
Main goal is not cure but
symptomatic treatment
Palliative cancer surgery
Palliative surgery is one of several
therapeutic modalities that are not
intended to cure the patient’s cancer, but
are carried out with an intention to:
- prolong life,
- relieve symptoms
- prevent symptoms
Magnitude of the problem
• 1/3 of the population will develop cancer
in their lifetime
•About 50% will develop metastases or
local recurrence and soon or later will
need palliative treatment
Timing
Fields of interest
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Primary tumors and metastases may
involve every organ
Multidisciplinary surgical teams might
be involved in the clinical course of
cancer patients
Gastroenterologic
surgery
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surgery related to the alimentary tract
from the oesophagus to the rectum
that improves functions, reduces pain
or stops bleedings
Neurologic
surgery
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surgery related to primary tumour or
metastasis to the brain or the
spine/spinal medulla in order to
preserve neurologic functions
Orthopaedic
surgery
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surgery related to pain and/or
fractures or required reinforcements of
arm, leg or spine due to bone
metastases
Thoracic
surgery
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surgery on metastases in the lungs,
reduction of compression of the
superior vena cava and procedures to
keep the airways open
Urologic
surgery
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surgery related to the urinary tracts in
order to provide passage from the
kidneys to the urinary bladder,
facilitate voiding of the bladder and
stop bleedings
Feb 2003
SINTEF Group is the largest independent research organisation in
Scandinavia
-Norwegian Cancer Plan,
-The Norwegian Center for Health Technology Assessment
Palliative cancer surgery
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The effect of several palliative surgical
procedures is not documented through
randomised controlled trials
It is difficult to give a comprehensive
assessment of whether or not the criterion of
effectiveness is filled
Few studies are available on the cost-benefit
relationship
Palliative cancer surgery
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Effect of procedures that reduce
symptoms from various organ
systems, irrespective of the origin
of the primary tumour.
Effect of procedures that aim at
preventing well-known future
symptoms from an incurable primary
tumour.
GI Surgery
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1. Dysphagia
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Jaundice (obstructive)
Gastric retention/bleeding
Intestinal obstruction/ileus
Intestinal bleeding
Dysphagia
Oesophageal CaNormal intake of fluids and nutrition
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Laser treatment
Self expanding metal better than rigid tubes
Endoscopic stenting = laser therapy (combination)
Gastrostomy/Jejunostomy vs TPN
Vakil N et al. A prospective, randomized, controlled trial of covered expandable metal stents in the palliation of
malignant esophageal obstruction at the gastroesophageal junction.
Am J Gastroenterol. 2001 Jun;96(6):1791-6
Alderson D et al. Laser recanalization versus endoscopic intubation in the palliation of malignant dysphagia.
Br J Surg. 1990 Oct;77(10):1151-3.
Dysphagia
Jaundice
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Association with Pruritus - Diarrhoea encephalopathy
Efficacy: Surg BP = stent (BP higher
complication rate)
Endoscopic better than Percutaneus (lower
mortality, higher success rate)
Bornman PC et al. Prospective controlled trial of transhepatic biliary endoprosthesis versus bypass surgery for
incurable carcinoma of head of pancreas. Lancet. 1986 Jan 11;1(8472):69-71.
Taylor MC et al. Biliary stenting versus bypass surgery for the palliation of malignant distal bile duct obstruction: a
meta-analysis. Liver Transpl. 2000 May;6(3):302-8.
Jaundice
Gastric obstruction/bleeding
Gastric obstruction/bleeding
If gastric cancer cannot be treated with a
curative intention
 Gastrectomy (total or partial) under certain
conditions is a valuable palliation (VS
BP/explorative laparotomy)
- longer survival
- prevention of serious bleeding
- removal of a relative obstacle in a passage
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Hartgrink HH et al. Value of palliative resection in gastric cancer. Br J Surg. 2002 Nov;89(11):1438-43.
Haugstvedt et al. The survival benefit of resection in patients with advanced stomach cancer: the Norwegian
multicenter experience. Norwegian Stomach Cancer Trial. World J Surg. 1989 Sep-Oct;13(5):617-21;
discussion 621-2.
Intestinal obstruction
Intestinal obstruction
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Relatively frequent
Non-surgical therapy laser,
cryotherapy, stenting
Requires palliative
gastroenterologic surgery (bypass,
resection and/or stoma)
About 50% of patients develop a new
obstruction within 2 to 3 months
Intestinal Bleeding
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Laser therapy, cryotherapy, embolization
might be an alternative to surgery
Surgery is often more comprehensive in
cancer of the rectum or the distal colon
CHT/XRT is a good option for high risk patient
Palliative cancer surgery
Prolonged
recovery
limited life
expectancy
Elevated morbidity
and mortality
Comorbidites
Problems
(elderly)
Limited compliance
Cost-effectiveness
Multiple symptoms
(prioritize )
Treatment vs prevention
Conclusions
Conclusions
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Extensive knowledge of the “natural”
course of the disease and defined endpoints
of the effectiveness of the procedure
Statistical estimates vs individual patient
Prophylactic procedures should be simple,
have a reliable effect and low risk of
complications
Surgeons are therefore often left with
their colleagues’ and their own
experience as a supplement
Una gran parte di quello che i medici
sanno e’ insegnato loro dai malati
(Marcel Proust)
Other surgeries
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Neurological surgery
- Cytoreductive surgery is useful in improving quality of life
and survival in intracranial cancer.
- Surgery of metastases to the brain is useful in patients with
single metastasis and otherwise stable cancer disease.
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Orthopedic surgery
- Metastases to the long bones and hip bone may require
surgery to relieve severe pain and maintain function.
- Surgical treatment of metastases to the back is required to
make support at a site of fracture and when pain relief has
not been achieved with radiation treatment.
Other surgeries
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Thoracic surgery
- Increased length of survival can be achieved in
surgical removal of metastases from primary cancers
of other organs (testis and soft tissue).
- Pain, obstructed breathing and infection can be
prevented by treating (laser or stenting) the
obstruction caused by cancer of the central airways.
- Cerebral symptoms and symptoms of localized
pressure caused by tumor growth obstructing the
superior vena cava can be prevented and treated by
thrombolysis, blocking or stenting of the vein.
Other surgeries
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Urological surgery
- The most common treatment of local symptoms such as
haemorrhage and obstruction due to cancer of the prostate
and bladder is transurethral resection (TUR) of the prostate
and the bladder.
- The use of stent is a good alternative in waiting for the
effect of hormonal treatment on the obstruction to take
place.
- The embolizing of the kidney artery in persisting
haemorrhage and radiating pain due to cancer of the kidney
has virtually replaced the conventional operation of
nephrectomy.
- The chosen treatment of malignant obstruction of the
ureter is now the minimally invasive technique of
pecutaneous nephrostomy or internal ureter stent.