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1.
BJOG ; 127(1): 18-26, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31538709

RESUMO

BACKGROUND: Anterior compartment prolapse is the most common pelvic organ prolapse (POP) with a range of surgical treatment options available. OBJECTIVES: To compare the clinical effectiveness and cost-effectiveness of surgical treatments for the repair of anterior POP. METHODS: We conducted a systematic review of randomised controlled trials comparing surgical treatments for women with POP. Network meta-analysis was possible for anterior POP, same-site recurrence outcome. A Markov model was used to compare the cost-utility of surgical treatments for the primary repair of anterior POP from a UK National Health Service perspective. MAIN RESULTS: We identified 27 eligible trials for the network meta-analysis involving eight surgical treatments tested on 3194 women. Synthetic mesh was the most effective in preventing recurrence at the same site. There was no evidence to suggest a difference between synthetic non-absorbable mesh, synthetic partially absorbable mesh, and biological mesh. The cost-utility analysis, which incorporated effectiveness, complications and cost data, found non-mesh repair to have the highest probability of being cost-effective. The conclusions were robust to model inputs including effectiveness, costs and utility values. CONCLUSIONS: Anterior colporrhaphy augmented with mesh appeared to be cost-ineffective in women requiring primary repair of anterior POP. There is a need for further research on long-term effectiveness and the safety of mesh products to establish their relative cost-effectiveness with a greater certainty. TWEETABLE ABSTRACT: New study finds mesh cost-ineffective in women with anterior pelvic organ prolapse.


Assuntos
Procedimentos Cirúrgicos em Ginecologia/economia , Prolapso de Órgão Pélvico/cirurgia , Telas Cirúrgicas/economia , Análise Custo-Benefício , Feminino , Procedimentos Cirúrgicos em Ginecologia/métodos , Humanos , Meta-Análise em Rede , Prolapso de Órgão Pélvico/economia , Anos de Vida Ajustados por Qualidade de Vida , Ensaios Clínicos Controlados Aleatórios como Assunto , Prevenção Secundária/economia , Resultado do Tratamento
2.
BJOG ; 127(1): 28-35, 2020 01.
Artigo em Inglês | MEDLINE | ID: mdl-31541614

RESUMO

BACKGROUND: Mesh surgery for stress urinary incontinence or pelvic organ prolapse can result in complications such as mesh exposure, mesh extrusion, voiding dysfunction, dyspareunia, and pain. There is limited knowledge or guidance on the effective management for mesh-related complications. OBJECTIVE: To determine the best management of mesh complications; a systematic review was conducted as part of the national clinical guideline 'Urinary incontinence (update) and pelvic organ prolapse in women: management'. SEARCH STRATEGY: Search strategies were developed for each indication for referral. SELECTION CRITERIA: Relevant interventions included complete or partial mesh removal, mesh division, and non-surgical treatments such as vaginal estrogen. DATA COLLECTION AND ANALYSIS: Characteristics and outcome data were extracted, and as a result of the heterogeneous nature of the data a narrative synthesis was conducted. MAIN RESULTS: Twenty-four studies were included; five provided comparative data and four studies stated the indication for referral. Reported outcomes (including pain, dyspareunia, satisfaction, quality of life, incontinence, mesh exposure, and recurrence) and the reported incidences of these varied widely. CONCLUSIONS: The current evidence base is limited in quantity and quality and does not permit firm recommendations to be made on the most effective management for mesh-related complications. Robust data are needed so that mesh complications can be managed effectively in the future. TWEETABLE ABSTRACT: Systematic review demonstrates that the outcomes following mesh revision surgery are highly variable.


Assuntos
Prolapso de Órgão Pélvico/cirurgia , Telas Cirúrgicas/efeitos adversos , Incontinência Urinária por Estresse/cirurgia , Adolescente , Adulto , Idoso , Perda Sanguínea Cirúrgica , Dispareunia/etiologia , Feminino , Humanos , Complicações Intraoperatórias/etiologia , Pessoa de Meia-Idade , Satisfação do Paciente , Complicações Pós-Operatórias/etiologia , Qualidade de Vida , Recidiva , Disfunções Sexuais Fisiológicas/etiologia , Resultado do Tratamento , Adulto Jovem
4.
Br J Surg ; 103(10): 1259-68, 2016 Sep.
Artigo em Inglês | MEDLINE | ID: mdl-27488593

RESUMO

BACKGROUND: After potentially curative resection of primary colorectal cancer, patients may be monitored by measurement of carcinoembryonic antigen and/or CT to detect asymptomatic metastatic disease earlier. METHODS: A systematic review and meta-analysis was conducted to find evidence for the clinical effectiveness of monitoring in advancing the diagnosis of recurrence and its effect on survival. MEDLINE (Ovid), Embase, the Cochrane Library, Web of Science and other databases were searched for randomized comparisons of increased intensity monitoring compared with a contemporary standard policy after resection of primary colorectal cancer. RESULTS: There were 16 randomized comparisons, 11 with published survival data. More intensive monitoring advanced the diagnosis of recurrence by a median of 10 (i.q.r. 5-24) months. In ten of 11 studies the authors reported no demonstrable difference in overall survival. Seven RCTs, published from 1995 to 2016, randomly assigned 3325 patients to a monitoring protocol made more intensive by introducing new methods or increasing the frequency of existing follow-up protocols versus less invasive monitoring. No detectable difference in overall survival was associated with more intensive monitoring protocols (hazard ratio 0·98, 95 per cent c.i. 0·87 to 1·11). CONCLUSION: Based on pooled data from randomized trials published from 1995 to 2016, the anticipated survival benefit from surgical treatment resulting from earlier detection of metastases has not been achieved.


Assuntos
Assistência ao Convalescente , Neoplasias Colorretais/diagnóstico por imagem , Neoplasias Colorretais/cirurgia , Assistência ao Convalescente/métodos , Neoplasias Colorretais/mortalidade , Humanos , Metástase Neoplásica , Recidiva Local de Neoplasia/diagnóstico por imagem , Recidiva Local de Neoplasia/mortalidade , Análise de Sobrevida , Resultado do Tratamento
11.
Int J Palliat Nurs ; 17(2): 68-74, 2011 Feb.
Artigo em Inglês | MEDLINE | ID: mdl-21378690

RESUMO

OBJECTIVE: Most patients with non-small cell lung cancer (NSCLC) present with an incurable, advanced disease, and treatment decisions may be hard. This study explored the factors that influence patients' choice of treatment during the oncologist-patient consultation. DESIGN: Semi-structured interviews conducted within 1 month of a consultation with an oncologist. PARTICIPANTS: Five patients newly diagnosed with incurable NSCLC and facing a treatment decision following a consultation with an oncologist. SETTING: A regional oncology unit in the UK. RESULTS: Some of the participants who opted for chemotherapy had made a decision before seeing the oncologist, presented with fewer symptoms, had been more active in seeking information before the consultation, and were willing to accept the risk of side effects. Participants opting for radiotherapy were not willing to accept the risk of side effects for the possibility of a small survival gain and instead focused on symptom relief. CONCLUSION: Some participants sought information before the consultation from various formal and informal sources. This may undermine the oncologist-patient consultation as the information may be incomplete or inaccurate. Patients vary in their willingness to accept risks for small potential gains. More research is required into methods to communicate the extent of the risks of treatment. The Clinical Nurse Specialist performed a valuable role for the patients and was seen as a trusted source of information.


Assuntos
Carcinoma Pulmonar de Células não Pequenas/terapia , Neoplasias Pulmonares/terapia , Participação do Paciente , Adulto , Idoso , Carcinoma Pulmonar de Células não Pequenas/psicologia , Feminino , Humanos , Neoplasias Pulmonares/psicologia , Masculino , Pessoa de Meia-Idade , Reino Unido
12.
Br J Cancer ; 102 Suppl 1: S24-9, 2010 Apr 13.
Artigo em Inglês | MEDLINE | ID: mdl-20386547

RESUMO

A broad range of studies suggest a two-way relationship between cancer and venous thromboembolism (VTE). Patients with cancer have consistently been shown to be at elevated risk for VTE; this risk is partly driven by an intrinsic hypercoagulable state elicited by the tumour itself. Conversely, thromboembolic events in patients without obvious risk factors are often the first clinical manifestation of an undiagnosed malignancy. The relationship between VTE and cancer is further supported by a number of trials and meta-analyses which, when taken together, strongly suggest that antithrombotic therapy can extend survival in patients with cancer by a mechanism that extends beyond its effect in preventing VTE. Moreover, accumulating evidence from in vitro and in vivo studies has shown that tumour growth, invasion, and metastasis are governed, in part, by elements of the coagulation system. On 22 May 2009, a group of health-care providers based in the United Kingdom met in London, England, to examine recent advances in cancer-associated thrombosis and its implications for UK clinical practice. As part of the discussion, attendees evaluated evidence for and against an effect of antithrombotic therapy on survival in cancer. This paper includes a summary of the data presented at the meeting and explores potential mechanisms by which antithrombotic agents might exert antitumour effects. The summary is followed by a consensus statement developed by the group.


Assuntos
Fibrinolíticos/uso terapêutico , Neoplasias/complicações , Neoplasias/mortalidade , Tromboembolia Venosa/tratamento farmacológico , Heparina de Baixo Peso Molecular/uso terapêutico , Humanos
13.
Clin Oncol (R Coll Radiol) ; 22(5): 347-55, 2010 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-20427167

RESUMO

In the past 15 years, the treatment of locally advanced non-small cell lung cancer (NSCLC) has shifted from radiotherapy alone. There are now schedules using induction chemotherapy, concurrent chemoradiation using either radiosensitising doses of chemotherapy or full-dose chemotherapy, consolidation chemotherapy after radiation or combinations of these options. There is no consensus on the optimal chemotherapy regimen and its scheduling and the issue of radiation dose and optimal fractionation equally remains unresolved. This overview is in two sections. First, we have evaluated a selection of international guidelines on the management of locally advanced NSCLC. We assessed the methodology by which individual guidelines were produced and the levels of evidence quoted in support of the recommendations. Second, we have updated the literature search of the 2004 Cochrane review on concurrent chemoradiation. Trials were identified that compared sequential with concurrent chemoradiation using median survival as the primary outcome measure. Two-year survival and toxicity were evaluated as secondary outcome measures. Eleven trials were identified, of which six fulfilled criteria for inclusion. The median survival for concurrent treatment was 16-17 months compared with 13-15 months with sequential treatment. Treatment-related mortality was 3% for concurrent treatment and 1.7% for sequential treatment. The rate of grade 3 or worse oesophagitis was 19% in concurrent treatment compared with 3% for sequential treatment. In conclusion, chemotherapy adds benefit to radiotherapy treatment of locally advanced NSCLC. Concurrent chemoradiation is associated with significant toxicity. The evidence to support concurrent chemoradiation as the standard of care is not robust, in spite of its recommendation within a number of guidelines. Further trials should be supported.


Assuntos
Carcinoma Pulmonar de Células não Pequenas/tratamento farmacológico , Carcinoma Pulmonar de Células não Pequenas/radioterapia , Neoplasias Pulmonares/tratamento farmacológico , Neoplasias Pulmonares/radioterapia , Guias de Prática Clínica como Assunto , Antineoplásicos/administração & dosagem , Ensaios Clínicos como Assunto , Terapia Combinada , Humanos , Radioterapia
14.
Health Technol Assess ; 13 Suppl 1: 41-7, 2009 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-19567213

RESUMO

This paper presents a summary of the evidence review group (ERG) report into the clinical and cost-effectiveness of erlotinib for the treatment of relapsed non-small cell lung cancer (NSCLC), according to its licensed indication, based upon the evidence submission from Roche Products to the National Institute for Health and Clinical Excellence (NICE) as part of the single technology appraisal (STA) process. The submitted clinical evidence includes one randomised controlled trial (RCT) (BR21) investigating the effect of erlotinib versus placebo, which demonstrates that erlotinib significantly increases median overall survival, progression-free survival and response rate compared with placebo. The majority of patients in the trial experienced non-haematological drug-related adverse effects. Currently there are no trials that directly compare erlotinib with any other second-line chemotherapy agent. For the purposes of indirect comparison, the manufacturer's submission provides a narrative discussion of data from 11 RCTs investigating the use of docetaxel. From these data the manufacturer concludes that erlotinib has similar clinical efficacy levels to docetaxel but results in fewer serious haematological adverse events; however, it is difficult to compare the results of BR21 with those of the docetaxel trials or with current UK clinical practice because, for example, the BR21 patient population is younger than that expected to present in UK clinical practice and almost half of the BR21 participants received erlotinib as third-line chemotherapy, with third-line chemotherapy being rare in the UK. The manufacturer's submission included a three-state model comparing erlotinib with docetaxel, reporting an incremental cost-effectiveness ratio (ICER) of 1764 pounds per quality-adjusted life-year (QALY) gained for erlotinib compared with docetaxel. Rerunning the manufacturer's economic model with varied parameters and assumptions increases the ICER to in excess of 52,000 pounds per QALY gained. There is still a large amount of unquantifiable uncertainty in the model and it is unlikely that erlotinib could be considered to be cost-effective compared with docetaxel at a willingness to pay of 30,000 pounds and there may even be the potential for docetaxel to dominate erlotinib. Because of the limitations of the indirect analysis undertaken by the manufacturer and the subsequent economic modelling exercise there is a need for a head-to-head trial comparing erlotinib with docetaxel. The guidance issued by NICE in February 2007 as a result of the STA states that erlotinib is not recommended for the treatment of locally advanced or metastatic NSCLC.


Assuntos
Carcinoma Pulmonar de Células não Pequenas/tratamento farmacológico , Neoplasias Pulmonares/tratamento farmacológico , Inibidores de Proteínas Quinases/uso terapêutico , Quinazolinas/uso terapêutico , Carcinoma Pulmonar de Células não Pequenas/economia , Análise Custo-Benefício , Cloridrato de Erlotinib , Humanos , Neoplasias Pulmonares/economia , Recidiva Local de Neoplasia , Inibidores de Proteínas Quinases/economia , Anos de Vida Ajustados por Qualidade de Vida , Quinazolinas/economia , Ensaios Clínicos Controlados Aleatórios como Assunto , Análise de Sobrevida , Avaliação da Tecnologia Biomédica
16.
Eur J Surg Oncol ; 35(7): 686-9, 2009 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-19153025

RESUMO

Pulmonary metastasectomy is undertaken for a range of cancers. The questions we raise here are specifically related to colorectal cancer, the commonest tumour for which pulmonary metastasectomy is undertaken. The primary objective of metastasectomy is to increase survival. There are no randomised trials in support of this practice nor are there any other forms of controlled studies. We present a critical look at the assumption of efficacy for this surgery and propose that a trial is needed and suggest a trial design.


Assuntos
Neoplasias Colorretais/patologia , Neoplasias Pulmonares/cirurgia , Humanos , Neoplasias Pulmonares/mortalidade , Neoplasias Pulmonares/secundário , Modelos Biológicos , Pneumonectomia , Ensaios Clínicos Controlados Aleatórios como Assunto , Projetos de Pesquisa
18.
Cochrane Database Syst Rev ; (3): CD004565, 2007 Jul 18.
Artigo em Inglês | MEDLINE | ID: mdl-17636767

RESUMO

BACKGROUND: Patients often do not get the information they require from doctors and nurses. To address this problem, interventions directed at patients to help them gather information in their healthcare consultations have been proposed and tested. OBJECTIVES: To assess the effects on patients, clinicians and the healthcare system of interventions which are delivered before consultations, and which have been designed to help patients (and/or their representatives) address their information needs within consultations. SEARCH STRATEGY: We searched: the Cochrane Central Register of Controlled Trials (CENTRAL, The Cochrane Library (issue 3 2006); MEDLINE (1966 to September 2006); EMBASE (1980 to September 2006); PsycINFO (1985 to September 2006); and other databases, with no language restriction. We also searched reference lists of articles and related reviews, and handsearched Patient Education and Counseling (1986 to September 2006). SELECTION CRITERIA: Randomised controlled trials of interventions before consultations designed to encourage question asking and information gathering by the patient. DATA COLLECTION AND ANALYSIS: Two researchers assessed the search output independently to identify potentially-relevant studies, selected studies for inclusion, and extracted data. We conducted a narrative synthesis of the included trials, and meta-analyses of five outcomes. MAIN RESULTS: We identified 33 randomised controlled trials, from 6 countries and in a range of settings. A total of 8244 patients was randomised and entered into studies. The most common interventions were question checklists and patient coaching. Most interventions were delivered immediately before the consultations.Commonly-occurring outcomes were: question asking, patient participation, patient anxiety, knowledge, satisfaction and consultation length. A minority of studies showed positive effects for these outcomes. Meta-analyses, however, showed small and statistically significant increases for question asking (standardised mean difference (SMD) 0.27 (95% confidence interval (CI) 0.19 to 0.36)) and patient satisfaction (SMD 0.09 (95% CI 0.03 to 0.16)). There was a notable but not statistically significant decrease in patient anxiety before consultations (weighted mean difference (WMD) -1.56 (95% CI -7.10 to 3.97)). There were small and not statistically significant changes in patient anxiety after consultations (reduced) (SMD -0.08 (95%CI -0.22 to 0.06)), patient knowledge (reduced) (SMD -0.34 (95% CI -0.94 to 0.25)), and consultation length (increased) (SMD 0.10 (95% CI -0.05 to 0.25)). Further analyses showed that both coaching and written materials produced similar effects on question asking but that coaching produced a smaller increase in consultation length and a larger increase in patient satisfaction. Interventions immediately before consultations led to a small and statistically significant increase in consultation length, whereas those implemented some time before the consultation had no effect. Both interventions immediately before the consultation and those some time before it led to small increases in patient satisfaction, but this was only statistically significant for those immediately before the consultation. There appear to be no clear benefits from clinician training in addition to patient interventions, although the evidence is limited. AUTHORS' CONCLUSIONS: Interventions before consultations designed to help patients address their information needs within consultations produce limited benefits to patients. Further research could explore whether the quality of questions is increased, whether anxiety before consultations is reduced, the effects on other outcomes and the impact of training and the timing of interventions. More studies need to consider the timing of interventions and possibly the type of training provided to clinicians.


Assuntos
Disseminação de Informação/métodos , Educação de Pacientes como Assunto/métodos , Ansiedade/diagnóstico , Humanos , Participação do Paciente , Ensaios Clínicos Controlados Aleatórios como Assunto
19.
Cochrane Database Syst Rev ; (4): CD002143, 2006 Oct 18.
Artigo em Inglês | MEDLINE | ID: mdl-17054152

RESUMO

BACKGROUND: Palliative radiotherapy to the chest is often used in patients with lung cancer, but radiotherapy regimens are more often based on tradition than research results. OBJECTIVES: To discover the most effective and least toxic regimens of palliative radiotherapy for non-small cell lung cancer, and whether higher doses increase survival. SEARCH STRATEGY: The electronic databases MEDLINE, EMBASE, Cancerlit and the Cochrane Central Register of Controlled Trials, reference lists, handsearching of journals and conference proceedings, and discussion with experts were used to identify potentially eligible trials, published and unpublished. SELECTION CRITERIA: Randomised controlled clinical trials comparing different regimens of palliative radiotherapy in patients with non-small cell lung cancer. DATA COLLECTION AND ANALYSIS: Fourteen randomised trials were reviewed. There were important differences in the doses of radiotherapy investigated, the patient characteristics and the outcome measures. Because of this heterogeneity no meta-analysis was attempted. MAIN RESULTS: There is no strong evidence that any regimen gives greater palliation. Higher dose regimens give more acute toxicity, especially oesophagitis. There is evidence for a modest increase in survival (5% at 1 year and 3% at 2 years) in patients with better performance status (PS) given higher dose radiotherapy. Some regimens are associated with an increased risk of radiation myelitis. AUTHORS' CONCLUSIONS: The majority of patients should be treated with short courses of palliative radiotherapy, of 1 or 2 fractions. Care should be taken with the dose to the spinal cord. The use of high dose palliative regimens should be considered for and discussed with selected patients with good performance status. More research is needed into reducing the acute toxicity of large fraction regimens and into the role of radical compared to high dose palliative radiotherapy. In the future, large trials comparing different RT regimens may be difficult to set up because of the increasing use of systemic chemotherapy. Trials looking at how best to integrate these two modalities, particularly in good PS patients, need to be carried out.


Assuntos
Carcinoma Pulmonar de Células não Pequenas/radioterapia , Neoplasias Pulmonares/radioterapia , Cuidados Paliativos , Carcinoma Pulmonar de Células não Pequenas/mortalidade , Humanos , Neoplasias Pulmonares/mortalidade , Dosagem Radioterapêutica , Ensaios Clínicos Controlados Aleatórios como Assunto
20.
Clin Oncol (R Coll Radiol) ; 18(5): 378-82, 2006 Jun.
Artigo em Inglês | MEDLINE | ID: mdl-16817328

RESUMO

AIMS: In small cell lung cancer (SCLC), consolidation thoracic irradiation (CTI) increases 3-year absolute survival by 5.4% in patients with limited disease and a complete response to chemotherapy. Early concurrent thoracic radiotherapy has been shown to improve local control and prolong survival compared with CTI in some trials. The standard management of patients with SCLC in southeast Wales is CTI in individuals with limited disease and a complete response to chemotherapy. A review of patients with SCLC was carried out to establish whether survival locally is comparable with that reported in published studies, and if patients given CTI have survival comparable with that reported in studies where early concurrent thoracic radiotherapy was used. MATERIALS AND METHODS: Between January 2000 and December 2002, 303 patients were registered with SCLC in southeast Wales. One hundred and fifteen (47%) patients had limited disease and 60/115 (52%) received CTI. RESULTS: Patients with limited disease receiving CTI had a median survival of 17.7 months (95% confidence interval: 15-27.9 months). The 2- and 5-year survivals were 38 and 13%, respectively. CONCLUSIONS: These results compare favourably with previously published studies on SCLC. There are no plans to change our current treatment policy for SCLC in southeast Wales.


Assuntos
Carcinoma de Células Pequenas/radioterapia , Neoplasias Pulmonares/radioterapia , Adulto , Idoso , Idoso de 80 Anos ou mais , Carcinoma de Células Pequenas/mortalidade , Terapia Combinada , Fracionamento da Dose de Radiação , Feminino , Humanos , Neoplasias Pulmonares/mortalidade , Masculino , Pessoa de Meia-Idade , Estadiamento de Neoplasias , Taxa de Sobrevida , País de Gales
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