Time to get real

Oncologists Are 'Sacrificing Common Sense' in Pursuit of Innovation

https://tinyurl.com/vxpmj7m

            This article by Bish Gyawali an oncologist and academic from Canada looks at oncologist’s reaction to clinical trials, which do not fit with their expectations. The recent GOG-0213 trial previously reported on this blog is cited as an example*. 

            The trial challenged the general belief that further surgery for ovarian patients after recurrence was beneficial. In fact the evidence shows no benefit, with overall survival being decreased on average by 14 months if surgery was repeated. Despite this finding many oncologists continue to recommend second surgery because it seems logical so to do. 

            Gyawali says there is a need for critical appraisal of current practice and that an obsessive quest for new drugs has taken precedence over common sense. He states that public funding of non-drug trials is essential and that the end point of all trials should be overall survival not the “surrogate” measurement of progression free survival. In addition quality of life assessment should be mandatory, (less than half of all oncology drug trials measure this).

*    https://tinyurl.com/swx9szb

COVID19 and cancer

COVID-19 Infection in Patients With Cancer in China

https://tinyurl.com/v54cbjs

            It has been thought that patients who already have cancer and who are exposed to the COVID19 virus would be more likely to be infected and have worse outcomes.

            This early study from China supports both these suggestions. It seems that it is approximately four times more likely for a patient with cancer to be infected than for the normal healthy population. 

            In addition patients with cancer who have been infected with the COVID19 virus are five times more likely to have a poor outcome requiring ventilation or resulting in death. For those patients who have had recent surgery or chemotherapy the risk of a poor outcome was even greater.

            It is suggested that surgery or chemotherapy should be delayed when there is a high risk of infection, that patients with cancer should where possible be isolated from contact with the virus, and that patients with cancer and COVID19 infection need more intensive therapy.

Better post-op care

Gynecologic Oncology Spotlight: Enhanced Recovery Pathways Improve Patient Outcomes

https://tinyurl.com/ww4rt5t

            The postoperative care for ovarian cancer patients is difficult. There is the problem of too many patients being discharged too soon, causing subsequent readmission, complications, and patient dissatisfaction.

            A proactive approach to this postoperative care has been established known as Enhanced Recovery After Surgery (ERAS). The protocols included in ERAS include aggressive anticoagulation therapy, minimal use of drains and in-dwelling tubes enabling early ambulation, and targeted pain management without opioids, using local anaesthetic epidural block. Wound infection is avoided by local cleansing of the skin prior to surgery and using negative pressure dressings. 

            Early ambulation, pain control, and prevention of infection improve the quality of life and also enable an earlier start to chemotherapy with hopefully beneficial effect.

Take the tubes with the gall bladder too

Prophylactic salpingectomy for prevention of ovarian cancer at the time of elective laparoscopic cholecystectomy

https://tinyurl.com/tkb3y5p

            There is strong evidence that most epithelial ovarian cancer starts in the fallopian tube. Pre malignant change is seen in 6% of women with a strong family history of ovarian cancer. It is recommended that women who are about to have pelvic surgery should be offered the choice of salpingectomy i.e. removal of the fallopian tubes at the same time.

            This study explores the acceptability and consequences of a similar offer at the time of abdominal surgery, in particular cholecystectomy i.e. removal of the gall bladder. Cholecystectomy is a common operation, with more than 600,000 being done each year in the US. Up to 40% of women over 60 have gallstones.

           Two thirds of women elected to have additional salpingectomy, when offered at the time of cholecystectomy, it was possible to perform the procedure without difficulty in 98%, and the extra operating time was about 13 minutes. There was no increase in postoperative complications. The specimens were not examined for pre malignant change. One woman did subsequently develop ovarian cancer and the specimen was reviewed, pre malignant change was noted in this instance

Blood test may prevent unnecessary surgery

Pre-operative sera interleukin-6 in the diagnosis of high-grade serous ovarian cancer

https://tinyurl.com/tkcfadb

            A mass detected in the ovary may have an indeterminate appearance. Frequently surgery and complete removal is required to exclude ovarian cancer.  Assessment of blood serum levels of a protein named CA125 has been used to separate between a malignant and benign cause for an ovarian mass. When used as part of a Risk of Malignancy Index there is a false positive rate of 13%*.

            This study from Melbourne, Australia looked at markers of inflammation in 68 patients suspected of having ovarian cancer. It has previously been demonstrated that ovarian cancer stimulates an inflammatory response.

            Of the 68 women recruited for the study, 33 were subsequently shown to have stage III-IV high-grade serous ovarian cancer. One marker: IL-6 was a good indicator of malignancy. When a high level of IL-6 was measured, no false positive results were noted. The study is limited by the size and the make-up of the study group. Validation, with age-matched controls is indicated.

·      https://tinyurl.com/wlkhqfb