Can anaesthetic technique influence cancer outcome? The next steps…

Whether anaesthetic technique during potentially curative cancer surgery influences recurrence is a question that dates to two publications about 15 yr ago, each of which presented associations between use regional anaesthesia and improved outcomes.1Exadaktylos A.K. Buggy D.J. Moriarty D.C. Mascha E. Sessler D.I. Can anesthetic for primary breast affect or metastasis?.Anesthesiology. 2006; 105: 660-664Crossref PubMed Scopus (649) Google Scholar,2Biki B. Fitzpatrick J.M. Anesthetic radical prostatectomy affects recurrence: retrospective analysis.Anesthesiology. 2008; 109: 180-187Crossref (474) Scholar There good basic in vitro vivo support potential benefit from analgesia.3Hiller J.G. Perry N.J. Poulogiannis G. Riedel Sloan E.K. Perioperative events influence risk after surgery.Nat Rev Clin Oncol. 2018; 15: 205-218Crossref (163) Specifically, analgesia reduces the surgical stress response, eliminates need volatile opioids, both impair natural killer cell function, host defence against cancer.4Wall T. Sherwin A. Ma D. Influence perioperative analgesic interventions on oncological outcomes: narrative review.Br J Anaesth. 2019; 123: 135-150Abstract Full Text PDF (70) In interim, plethora additional analyses various techniques types reported conflicting, but largely equivocal, results.4Wall Scholar,5Buggy Borgeat Cata J. et al.Consensus statement BJA workshop anaesthesia.Br 2015; 114: 2-3Abstract (66) have also been several reanalyses patients who were randomised epidural other reasons; those results equivocal.6Myles P.S. Peyton P. Silbert al.Perioperative major abdominal recurrence-free survival: trial.BMJ. 2011; 342: d1491Crossref (214) Scholar,7Christopherson R. James K.E. Tableman M. Marshall Johnson F.E. Long-term survival colon surgery: variation associated with choice anesthesia.Anesth Analg. 107: 325-332Crossref (207) The only trial enrolled more than 2100 women cancer, showed no difference disease-free recurrence.8Sessler Pei L. Huang Y. al.Recurrence general anaesthesia: controlled trial.Lancet. 394: 1807-1815Abstract (110) limitation third had relatively minor surgery, namely, lumpectomy node dissection. A consequence response was minor, as pain opioid use. authors therefore postulated might yet prove helpful larger operations. It thus encouraging this issue British Journal Anaesthesia presents anaesthesia–analgesia colorectal surgery. three-centre Swedish beginning 2011, just 200 300 planned recruited by 2017 when terminated. stopped early because it became increasingly difficult justify giving epidurals minimally invasive surgery.9Falk W. Magnuson Eintrei C. al.Comparison intravenous following randomised, trial.Br 2021; 127: 65-74Abstract (3) investigators' pragmatic design laudable makes their findings generally applicable. Efficacy an important component analgesia, technical failures are common. To credit, seven (6%) receive excluded analysis failures. Any data well-conducted trials welcome, these will surely be included meta-analyses. nonetheless aspects deserve consideration. registered outcome overall 5 survival. However, outcome. latter better one now most often used trials.10Buggy Freeman M.Z. al.Systematic review consensus definitions standardised endpoints medicine: postoperative outcomes.Br 121: 38-44Abstract (24) investigators do not explain why change made. sample-size estimate based reduction 40% 25%, large seems unlikely disease like influenced so many factors. fact, observed 30% amongst assigned anaesthetic-based patient-controlled vs 24% (P=0.35). treatment effect 20%, biologically plausible clinically meaningful. would require 1395 power at 80% interim analyses. Ideally, 90% include analyses, thereby requiring >1600 patients. current seriously underpowered, interpretation challenging. Fortunately, progress completed, published. For example, Outcomes Research Consortium session 2020 Annual Meeting ASA. One described 1575 alone, combination surgery.11Du Y.-T. Li Y.-W. Zhao B.-J. al.Long-term combined epidural-general anesthesia alone: follow-up randomized trial.Anesthesiology. (in press)Google 400 clinical diagnoses lung anaesthesia. Epidural did improve cancer-free either study (unpublished data). Available fairly strongly suggest does reduce there management outcomes reasons believe amide local lidocaine i.v. agent propofol immunity, recurrence.12Johnson Crowley P.D. Foley A.G. al.Effect metastasis sevoflurane ketamine-xylazine tumour resection murine model.Br 76-85Abstract (33) Scholar,13Freeman lidocaine, steroids pulmonary model surgery.Cancers (Basel). 11: 613Crossref (31) Both being tested recently started Volatile Related Cancer (VAPOR-C) (NCT04316013).14Dubowitz J.A. J.P. De Silva A.P. al.Volatile peri-operative related cancer: feasibility pilot control trial.Anaesthesia. https://doi.org/10.1111/anae.15354Crossref (5) Other RCTs evaluating Anesthesia: Survival After Radical Surgery—A Comparison Between Propofol Sevoflurane Anesthesia (CAN) (NCT01975064), General Anesthetics Resection Surgery (GA-CARES) (NCT03034096), completed China (NCT02660411). Should we abandon neuraxial surgery? Of course not: should indications, including stress-response reduction, opioid-sparing, analgesia. point, remains speculative whether any aspect improves outcomes. if can, enormous contribution human health. DJB proposed commentary, instigated initial content contributed reviewed intellectual input; BR DS original input tone content. member board Anaesthesia. effects multicentre trialBritish AnaesthesiaVol. 127Issue 1PreviewThoracic (TEA) has suggested compared systemic evidence, exclusively studies, contradictory. Full-Text Open Access