RESUMO
BACKGROUND: Highlighting the identified gaps in evidence-based research concerning advanced esophageal cancer (EC) treatment and care, this review evaluates the efficacy and safety of anticancer drugs compared to supportive care for advanced EC patients, aiming to assess the appropriateness of usual treatments and identify the gaps that need to be filled with primary research. METHODS: We searched (May 2022) MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), Epistemonikos, and trial registries (ClinicalTrials.gov and PROSPERO) for randomised controlled trials (RCTs) comparing anticancer drugs (chemotherapy, immunotherapy, or biological/targeted therapy) with supportive care in advanced EC. The results were summarised using GRADE summary of finding tables. RESULTS: We included 15 RCTs. Most studies did not have a special focus on EC, did not detail the treatment lines in all patients, and did not evaluate all outcomes. Anticancer drugs may result in a slight increase in overall survival (OS) (HR 0.78; 95% CI 0.71, 0.86; MD 0.83 months) and better progression-free survival (PFS) (HR 0.56 95% CI 0.49, 0.64, MD 0.68 months), but also may increase toxicity (RR 1.37; 95% CI 1.13, 1.65), without a significant improvement in quality of life. The certainty of evidence was low or very low due to indirectness of results and lack of specific focus on EC in some studies. CONCLUSION: RCTs on advanced EC lack specificity, detailed treatment line information, and evaluation of all relevant outcomes. Moreover, when they find any benefit, this is negligible. Therefore, the certainty to justify anticancer drug treatments instead of supportive care in advanced EC is low or very low, and this information should be actively shared with affected patients. More and better RCTs should be conducted to assess whether any old or new proposed treatment for advanced EC patients provides a better balance of benefits and harms than the supportive care. SYSTEMATIC REVIEW REGISTRATION: The study protocol was registered in OSF ( https://doi.org/10.17605/OSF.IO/7CHX6 ) on 2022-03-29.
Assuntos
Antineoplásicos , Neoplasias Esofágicas , Revisões Sistemáticas como Assunto , Humanos , Antineoplásicos/uso terapêutico , Neoplasias Esofágicas/tratamento farmacológico , Medicina Baseada em Evidências , Sobretratamento , Cuidados Paliativos , Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como AssuntoRESUMO
BACKGROUND: Despite national guidelines recommending omission of sentinel lymph node biopsy (SLNB) and post-lumpectomy radiotherapy (RT) in older women with early-stage, hormone receptor-positive (HR+) breast cancer, these practices persist. This pilot study assesses whether a decision aid can target patient-level determinants of low-value treatments. METHODS: We adapted and pilot-tested a decision aid in women ≥70 years old with early-stage HR â+ âbreast cancer. Primary outcomes included acceptability and appropriateness of the decision aid. Secondary outcomes included treatment choice and satisfaction with decision. RESULTS: Twenty-three patients enrolled in the trial. 19 completed survey one; 16 completed survey two. Primary outcomes demonstrated that 84% of patients agreed or strongly agreed the aid was acceptable and appropriate. Secondary outcomes demonstrated that 19% of patients underwent SLNB (below pre-intervention baseline), and 85% received adjuvant RT (change not statistically significant). CONCLUSIONS: We demonstrate that a decision aid may effectively target patient-level factors contributing to overuse of low-value therapies.
Assuntos
Neoplasias da Mama , Técnicas de Apoio para a Decisão , Sobretratamento , Biópsia de Linfonodo Sentinela , Humanos , Feminino , Neoplasias da Mama/patologia , Neoplasias da Mama/terapia , Projetos Piloto , Idoso , Estadiamento de Neoplasias , Idoso de 80 Anos ou mais , Mastectomia Segmentar , Radioterapia AdjuvanteRESUMO
In recent years, the incidence of thyroid cancer has rapidly increased, whereas the mortality rate has not risen correspondingly. Therefore, scholars at home and abroad have proposed the view of overdiagnosis in thyroid cancer, sparking intense debates about the phenomenon of overdiagnosis and overtreatment. A historical review and discussion of the primary reasons for the increase in thyroid cancer incidence and the improvement in treatment outcomes are beneficial. It helps clarify that the real increase in thyroid cancer is primarily due to the higher incidence rate, rather than overdiagnosis. Additionally, it allows us to reevaluate which factors guarantee favorable efficacy in thyroid cancer.
Assuntos
Neoplasias da Glândula Tireoide , Neoplasias da Glândula Tireoide/diagnóstico , Neoplasias da Glândula Tireoide/terapia , Humanos , Incidência , Sobrediagnóstico , SobretratamentoRESUMO
The management of low-risk differentiated thyroid cancer (DTC) has evolved over time toward treatment de-escalation. However, overtreatment with supraphysiological dose of levothyroxine (LT4) continues to be observed despite current clinical guideline. This study aimed to assess the actual thyrotropin suppressive therapy for low-risk DTC patients at an endocrine center in Bangkok. This retrospective study included patients with low-risk DTC who were regularly follow-up for at least 18 months at Theptarin Hospital between 2016 and 2022. The serum thyroid stimulating hormone (TSH) levels were stratified as TSHâ <â 0.1 mIU/L; TSH 0.1 to 0.5 mIU/L; TSH 0.5 to 2.0 mIU/L; and TSHâ >â 2.0 mIU/L. The initial risk stratification (IRS) and dynamic risk stratification were determined at 12 months of follow-up after completing the initial treatment and at the last visit. The clinical factors associated with overtreatment with LT4 were analyzed. A total of 102 patients (83.3% female, age at diagnosis 41.8â ±â 13.6 years, mean tumor size 1.6â ±â 1.0 cm) were evaluated with a mean follow-up of 5.9 years. The IRS classified 92.2% of patients after the initial treatment and 93.1% of patients at the last follow-up visit into the excellent response category. The mean LT4 daily dosage at the last follow-up was 121.3â ±â 44.8 µg/day. Serum TSH levels were in an appropriate target range according to IRS in only 8.8% (9/102) of the patients and then improved to 19.6% (20/102) at the last follow-up visit. Further analysis showed that treating physicians with ≥10 years of practice was associated with severe TSH suppression therapy (TSHâ <â 0.1 mIU/L). Despite the current clinical guideline recommendations and scientific evidences, less than one-fifth of low-risk DTC patients achieved the appropriate serum TSH target. While the proportion of an optimum LT4 suppressive had improved during the study period, further efforts are needed to overcome this clinical inertia.
Assuntos
Neoplasias da Glândula Tireoide , Tireotropina , Tiroxina , Humanos , Feminino , Masculino , Neoplasias da Glândula Tireoide/tratamento farmacológico , Neoplasias da Glândula Tireoide/patologia , Estudos Retrospectivos , Adulto , Tireotropina/sangue , Pessoa de Meia-Idade , Tiroxina/uso terapêutico , Tiroxina/administração & dosagem , Tailândia , Medição de Risco , SobretratamentoRESUMO
Ductal carcinoma in situ (DCIS) accounts for 15-25% of all breast cancer diagnoses. Its prognosis is excellent overall, the main risk being the occurrence of local breast events, as most cases of DCIS do not progress to invasive cancer. Systematic screening has greatly increased the incidence of this non-obligate precursor of invasion, lending urgency to the need to identify DCIS that is prone to invasive progression and distinguish it from non-invasion-prone DCIS, as the latter can be overdiagnosed and therefore overtreated. Treatment strategies, including surgery, radiotherapy, and optional endocrine therapy, decrease the risk of local events, but have no effect on survival outcomes. Active surveillance is being evaluated as a possible new option for low-risk DCIS. Considerable efforts to decipher the biology of DCIS have led to a better understanding of the factors that determine its variable natural history. Given this variability, shared decision making regarding optimal, personalised treatment strategies is the most appropriate course of action. Well designed, risk-based de-escalation studies remain a major need in this field.
Assuntos
Neoplasias da Mama , Carcinoma Intraductal não Infiltrante , Humanos , Neoplasias da Mama/terapia , Neoplasias da Mama/patologia , Feminino , Carcinoma Intraductal não Infiltrante/terapia , Carcinoma Intraductal não Infiltrante/patologia , Sobretratamento , Detecção Precoce de Câncer , Prognóstico , SubtratamentoAssuntos
Detecção Precoce de Câncer , Antígeno Prostático Específico , Neoplasias da Próstata , Humanos , Masculino , Pessoa de Meia-Idade , Biópsia/efeitos adversos , Biópsia/métodos , Detecção Precoce de Câncer/efeitos adversos , Detecção Precoce de Câncer/métodos , Calicreínas/sangue , Imageamento por Ressonância Magnética , Programas de Rastreamento/efeitos adversos , Programas de Rastreamento/métodos , Sobrediagnóstico/prevenção & controle , Sobretratamento/prevenção & controle , Valor Preditivo dos Testes , Próstata/diagnóstico por imagem , Próstata/patologia , Antígeno Prostático Específico/sangue , Neoplasias da Próstata/sangue , Neoplasias da Próstata/diagnóstico , Neoplasias da Próstata/diagnóstico por imagem , Neoplasias da Próstata/patologia , Ensaios Clínicos Controlados Aleatórios como Assunto , Conduta Expectante , IdosoAssuntos
Sobretratamento , Neoplasias Pancreáticas , Humanos , Neoplasias Pancreáticas/cirurgia , Neoplasias Pancreáticas/patologia , Carcinoma Ductal Pancreático/cirurgia , Carcinoma Ductal Pancreático/patologia , Carcinoma Ductal Pancreático/mortalidade , Pancreatectomia/métodos , Neoplasias Intraductais Pancreáticas/cirurgia , Adenocarcinoma Mucinoso/cirurgia , Adenocarcinoma Mucinoso/patologiaAssuntos
Diagnóstico Tardio , Sobrediagnóstico , Humanos , Sobretratamento , Detecção Precoce de CâncerRESUMO
Advances in the treatment of older women with early-stage breast cancer, particularly opportunities for de-escalation of therapy, have afforded patients and providers opportunity to individualize care. As the majority of women ≥65 have estrogen receptor-positive, HER2-negative disease, locoregional therapy (surgery and/or radiation) may be tailored based on a patient's physiologic age to avoid either over- or undertreatment. To determine who would derive benefit from more or less intensive therapy, an accurate assessment of an older patient's physiologic age and incorporation of patient-specific values are paramount. While there now exist well-validated geriatric assessment tools whose use is encouraged by the American Society of Clinical Oncology when considering systemic therapy, these instruments have not been widely integrated into the locoregional breast cancer care model. This review aims to highlight the importance of assessing frailty and the concepts of and over- and undertreatment, in the context of trial data supporting opportunities for safe deescalation of locoregional therapy, when treating older women with early-stage breast cancer.
Assuntos
Neoplasias da Mama , Avaliação Geriátrica , Sobretratamento , Humanos , Feminino , Neoplasias da Mama/terapia , Neoplasias da Mama/patologia , Idoso , Estadiamento de Neoplasias , Idoso de 80 Anos ou mais , Fragilidade , Fatores EtáriosRESUMO
INTRODUCTION: Total thyroidectomy is the traditional primary approach for papillary thyroid cancer. However, recent evidence supports conservative management for low-risk tumors like papillary thyroid microcarcinomas (PTMCs). This study explores the adoption of these practices in our community, using a cancer database to analyze treatment strategies. METHODS: A retrospective review of a 1433-patient institutional database identified 258 âPTMC cases. Outcomes, including 30-day mortality, reoperation rate, postoperative hypocalcemia, and recurrent laryngeal nerve (RLN) injury, were assessed. RESULTS: Of PTMC patients, 63.4% underwent total thyroidectomy, with higher rates of RLN injury (8.8% vs. 2.3%) and hypocalcemia (12.4% vs. 0.0%) compared to lobectomy. Non-endocrine surgeons had higher postoperative radioactive iodine administration rates (28.6% vs. 6.1%). Subgroup analysis revealed a shift in total thyroidectomy rates based on tumor size and surgery period. CONCLUSION: Our community favors total thyroidectomy for PTMC, despite associated complications. Enhanced awareness and adherence to PTMC best practice guidelines are warranted.