ACCANIMENTO TERAPEUTICO IN ACCANIMENTO TERAPEUTICO IN ONCOLOGIA:ONCOLOGIA:

VERO O FALSO PROBLEMA?VERO O FALSO PROBLEMA?

CONGRESSO REGIONALE DELLA SICP EMILIA ROMAGNACONGRESSO REGIONALE DELLA SICP EMILIA ROMAGNAReggio Emilia 18/04/2008Reggio Emilia 18/04/2008

Appropriatezze ed evidenzedi beneficio clinico in chirurgia

Giampaolo UgoliniGiampaolo UgoliniDip. di ChirurgiaDip. di ChirurgiaAz. Osp. Policlinico S.Orsola MalpighiAz. Osp. Policlinico S.Orsola Malpighi

Filippo Brunelleschi1377 - 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 CLINICOCASO CLINICO

66 yo F diagnosed with breast 66 yo F diagnosed with breast cancer in 1999: surg + CHT/XRTcancer in 1999: surg + CHT/XRT

2000 bone mets D3-D5: 2000 bone mets D3-D5: XRT/CHT/spinal stabilizationXRT/CHT/spinal stabilization

2002 multiple bone mets: CHT2002 multiple bone mets: CHT

2/2003 lung mets: CHT2/2003 lung mets: CHT

CASO CLINICOCASO CLINICO

4/2003: anal abscess4/2003: anal abscess

LOW RECTAL CANCERLOW RECTAL CANCER

What to do?What to do?Colostomy vs. APR Colostomy vs. APR Is it worthwile?Is it worthwile?Is it right?Is it right?Cost-Cost-effectiveness?effectiveness?

CASO CLINICOCASO CLINICO

4/2003: Abdominoperineal excision4/2003: Abdominoperineal excision

9/2004: bilat. ureteral 9/2004: bilat. ureteral stentingstenting12/2004: Small bowel obstruction 12/2004: Small bowel obstruction due to peritoneal carcinomatosis: due to peritoneal carcinomatosis: ex. lap. + ileostomyex. lap. + ileostomy

3/2005: exitus3/2005: exitus

Guidelines Have Done More Harm than Guidelines Have Done More Harm than GoodGood, , Amerling R et al. Blood PurifBlood Purif 26:73-76, 26:73-76, 20082008

Proliferation of practice guidelinesProliferation of practice guidelines

Uncertain impact on actual practice Uncertain impact on actual practice and outcomesand outcomes

They are unlikely to stimulate original They are unlikely to stimulate original researchresearch

Many guidelines are obsolete by the Many guidelines are obsolete by the time they are publishedtime they are published

? Conflict of interest? Conflict of interest

Guidelines Have Done More Harm than Guidelines Have Done More Harm than GoodGood, , Amerling R et al. Blood PurifBlood Purif 26:73-76, 26:73-76, 20082008

A 'one-size-fits-all' approach is A 'one-size-fits-all' approach is likely to benefit some, but not alllikely to benefit some, but not all

Guidelines do not encourage Guidelines do not encourage clinicians to consider and treat clinicians to consider and treat each patient as an individualeach patient as an individual

Certain patients may be harmed Certain patients may be harmed by adherence to specific by adherence to specific guidelinesguidelines

““Variability is the law of life, and as Variability is the law of life, and as no two faces are the same, so no no two faces are the same, so no two bodies are alike, and no two two bodies are alike, and no two individuals react alike and behave individuals react alike and behave alike under abnormal conditions alike under abnormal conditions wich we know as disease”wich we know as disease”

““Gentlemen, if you want a Gentlemen, if you want a profession in which everything is profession in which everything is certain you had better give up certain you had better give up medicine!”medicine!”

William Osler, 1926William Osler, 1926

Palliative cancer surgery

Main goal is not cure butsymptomatic 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

Primary tumors and metastases Primary tumors and metastases may involve every organmay involve every organ

Multidisciplinary surgical teams Multidisciplinary surgical teams might be involved in the clinical might be involved in the clinical course of cancer patientscourse of cancer patients

Gastroenterologicsurgery

surgery related to the alimentary tract from the oesophagus to the rectum that improves functions, reduces pain or stops bleedings

Neurologic surgery

surgery related to primary tumour or metastasis to the brain or the spine/spinal medulla in order to preserve neurologic functions

Orthopaedic surgery

surgery related to pain and/or fractures or required reinforcements of arm, leg or spine due to bone metastases

Thoracicsurgery

surgery on metastases in the lungs, reduction of compression of the superior vena cava and procedures to keep the airways open

Urologicsurgery

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

SINTEF Group is the largest independent research organisation in Scandinavia -Norwegian Cancer Plan, -The Norwegian Center for Health Technology Assessment

Feb 2003

Palliative cancer surgery

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

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.

Palliative cancer surgery

GI SurgeryGI Surgery

1. Dysphagia 2. Jaundice (obstructive) 3. Gastric retention/bleeding 4. Intestinal obstruction/ileus 5. Intestinal bleeding

Dysphagia

Oesophageal CaNormal intake of fluids and nutrition

- 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

Association with Pruritus - Diarrhoea - Association with Pruritus - Diarrhoea - encephalopathyencephalopathy

Efficacy: Surg BP = stent (BP higher Efficacy: Surg BP = stent (BP higher complication rate)complication rate)

Endoscopic better than Percutaneus Endoscopic better than Percutaneus (lower mortality, higher success rate)(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

passageHartgrink 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

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

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

limited life expectancy

Comorbidites

(elderly)

Elevated morbidityand mortality

Cost-effectiveness

Limited compliance

Prolonged recovery

Problems

Multiple symptoms(prioritize )

Treatment vs prevention

ConclusionsConclusions

ConclusionsConclusions

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 medicisanno e’ insegnato loro dai malati

  (Marcel Proust)

Other surgeriesOther surgeries 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.

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 surgeriesOther surgeries

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 surgeriesOther surgeries 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.