Zhang Yue-Lun, Pei Li-Jian, Sun Chen, Zhao Meng-Yun, Che Lu, Huang Yu-Guang
Medical Research Center, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China.
Department of Anesthesiology, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100730, China.
Chin Med J (Engl). 2021 Sep 29;134(20):2403-2411. doi: 10.1097/CM9.0000000000001676.
Whether regional anesthesia may help to prevent disease recurrence in cancer patients is still controversial. The stage of cancer at the time of diagnosis is a key factor that defines prognosis and is one of the most important sources of heterogeneity for the treatment effect. We sought to update existing systematic reviews and clarify the effect of regional anesthesia on cancer recurrence in late-stage cancer patients.
Medline, Embase, and Cochrane Library were searched from inception to September 2020 to identify randomized controlled trials (RCTs) and cohort studies that assessed the effect of regional anesthesia on cancer recurrence and overall survival (OS) compared with general anesthesia. Late-stage cancer patients were primarily assessed according to the American Joint Committee on Cancer Cancer Staging Manual (eighth edition), and the combined hazard ratio (HR) from random-effects models was used to evaluate the effect of regional anesthesia.
A total of three RCTs and 34 cohort studies (including 64,691 patients) were identified through the literature search for inclusion in the analysis. The risk of bias was low in the RCTs and was moderate in the observational studies. The pooled HR for recurrence-free survival (RFS) or OS did not favor regional anesthesia when data from RCTs in patients with late-stage cancer were combined (RFS, HR = 1.12, 95% confidence interval [CI]: 0.58-2.18, P = 0.729, I2 = 76%; OS, HR = 0.86, 95% CI: 0.63-1.18, P = 0.345, I2 = 48%). Findings from observational studies showed that regional anesthesia may help to prevent disease recurrence (HR = 0.87, 95% CI: 0.78-0.96, P = 0.008, I2 = 71%) and improve OS (HR = 0.88, 95% CI: 0.79-0.98, P = 0.022, I2 = 79%).
RCTs reveal that OS and RFS were similar between regional and general anesthesia in late-stage cancers. The selection of anesthetic methods should still be based on clinical evaluation, and changes to current practice need more support from large, well-powered, and well-designed studies.
区域麻醉是否有助于预防癌症患者疾病复发仍存在争议。癌症诊断时的分期是决定预后的关键因素，也是治疗效果异质性的最重要来源之一。我们试图更新现有的系统评价，并阐明区域麻醉对晚期癌症患者癌症复发的影响。
检索Medline、Embase和Cochrane图书馆自建库至2020年9月的文献，以识别评估区域麻醉与全身麻醉相比对癌症复发和总生存期（OS）影响的随机对照试验（RCT）和队列研究。晚期癌症患者主要根据美国癌症联合委员会癌症分期手册（第八版）进行评估，并使用随机效应模型的合并风险比（HR）来评估区域麻醉的效果。
通过文献检索共纳入三项RCT和34项队列研究（包括64,691例患者）进行分析。RCT中的偏倚风险较低，观察性研究中的偏倚风险为中等。当合并晚期癌症患者RCT的数据时，区域麻醉在无复发生存期（RFS）或OS方面并无优势（RFS，HR = 1.12，95%置信区间[CI]：0.58 - 2.18，P = 0.729，I² = 76%；OS，HR = 0.86，95% CI：0.63 - 1.18，P = 0.345，I² = 48%）。观察性研究结果显示，区域麻醉可能有助于预防疾病复发（HR = 0.87，95% CI：0.78 - 0.96，P = 0.008，I² = 71%）并改善OS（HR = 0.88，95% CI：0.79 - 0.98，P = 0.022，I² = 79%）。
RCT表明，晚期癌症患者区域麻醉和全身麻醉的OS和RFS相似。麻醉方法的选择仍应基于临床评估，当前实践的改变需要更多来自大型、有足够效力和精心设计研究的支持。
