cancer
The guideline is divided into sections which cover in detail specific topics relating to twelve groups of cancers: lung, upper gastrointestinal cancers, lower gastrointestinal cancers, breast cancer, gynaecological cancers, urological cancers, haematological cancers, skin cancers, head and neck including oral cancers, brain/central nervous system cancers, bone and sarcoma, and children’s and young people’s cancers.
Anthracyclines are used in the treatment of different types of childhood cancer. Unfortunately, one of the most important adverse effects of anthracyclines is damage to the heart. This can become manifest not only during treatment, but also years after the end of treatment. A well‐informed decision on the use of anthracyclines in the treatment of different types of childhood cancer should be based on the available evidence on both antitumour effects of anthracyclines and the risk for damage to the heart.
Malignant germ cell cancer of the ovary (type of ovarian cancer) is a very rare type of cancer. Malignant ovarian germ cell cancer is a term used to describe a group of heterogeneous rare tumours affecting the ovaries. These tumours start in the egg (ovum) producing cells of the ovary, whereas the more common epithelial ovarian cancers start in the cells that cover the surface of the ovary. Unlike epithelial ovarian cancers, these tumours are often diagnosed early and a combination of surgery and chemotherapy usually results in favourable long term overall survival. Due to its rarity, this review is based on only one very small RCT and one small retrospective study. The data from these studies were too sparse to adequately assess the effectiveness and safety of chemotherapy after surgery (adjuvant chemotherapy) in the treatment of malignant germ cell ovarian cancer. All comparisons were restricted to single study analyses and this review was only based on 32 women, so it was not adequately powered to detect differences in survival. Adverse effects of treatment and recurrence‐free survival were incompletely documented and QoL was not reported in any of the studies. We did not find any studies that reported specifically on adults as this disease usually afflicts younger people as opposed to the older population, so there were problems in separating data on adults and children in many of the studies. Many of the treatments used were taken from experiences of treating patients with testicular cancer, as they look similar under the microscope and behave similar clinically. Due to the small number of patients with malignant germ cell cancer in the two studies, our review shows that there were no good quality studies assessing the role of chemotherapy in this disease, be it in early or late stages. There was insufficient evidence to conclude that any form of chemotherapy or best supportive care is superior over the other. This review highlights the need for future good quality, well designed studies.
Ovarian cancer is a cancerous growth arising from different parts of the ovary. It is the sixth most common cancer among women. Most ovarian cancers are classified as epithelial. Ovarian epithelial cancer is a disease in which malignant (cancer) cells form in the tissue covering the ovary and most cases are epithelial. Primary surgery is performed to achieve optimal cytoreduction (surgical efforts aiming at removing the bulk of the tumour) as the amount of tumour that remains after surgery (residual disease) is one of the most important factors that is taken into account when determining a prognosis (prognostic factor) for survival of epithelial ovariancancer. Optimal cytoreductive surgery remains a subject of controversy to many practising obstetric gynaecologists who specialise in the diagnosis and treatment of women with cancer of the reproductive organs (gynae‐oncologists). The Gynaecologic Oncology Group (GOG) currently defines 'optimal' as having a small aggregation of remaining cancer cells after surgery (residual tumour nodules) each measuring 1 cm or less in maximum diameter, with complete cytoreduction (microscopic disease) being the ideal surgical outcome. Although the size of residual tumour masses after surgery has been shown to be an important prognostic factor for advanced ovarian cancer, there is limited evidence to support the conclusion that the surgical procedure is directly responsible for the superior outcome associated with less residual disease. This review assessed overall and progression‐free survival of optimal primary cytoreductive surgery for women with advanced epithelial ovarian cancer (stages III and IV). We found 11 retrospective studies that included more than 100 women and used a multivariate analysis (used statistical adjustment for important prognostic factors) and met our inclusion criteria. Analyses showed the prognostic importance of complete cytoreduction, where the residual disease is microscopic with no visible disease, as overall (OS) and progression‐free survival (PFS) were significantly prolonged in these groups of women. PFS was not reported in all of the studies but was sufficiently documented to allow firm conclusions to be drawn. When we compared suboptimal (> 1 cm) versus optimal (< 1 cm) cytoreduction the survival estimates were attenuated but remained statistically significant in favour of the lower volume disease group, but there was no significant difference in OS and only a borderline difference in PFS when residual disease of > 2 cm and < 2 cm were compared. There was a high risk of bias due to the retrospective nature of these studies. Adverse events, quality of life (QoL) and cost‐effectiveness were not reported by treatment arm or to a satisfactory level in any of the studies. During primary surgery for advanced stage epithelial ovarian cancer, all attempts should be made to achieve complete cytoreduction. When this is not achievable, the surgical goal should be optimal (< 1 cm) residual disease. Due to the high risk of bias in the current evidence, randomised controlled trials should be performed to determine whether it is the surgical intervention or patient‐related and disease‐related factors that are associated with the improved survival in these groups of women.
Ovarian cancer is the commonest cause of death in women with a female cancer. Opinions differ about whether women with advanced ovarian cancer do better if they have 'ultra‐radical' surgery which is much more extensive than standard surgery.
Worldwide, bladder cancer is common in both men and women. In most cases, thecancer occurs in the superficial layers of the bladder and can be surgically removed. However, in many people the cancer returns. Drugs placed directly into the bladder tissue following surgery are therefore often used to try to prevent thecancer recurring. Bacillus Calmette‐Guérin (BCG) is a live attenuated bacterium used for immunization against tuberculosis, and is safe and effective for that purpose; it has also been licensed by the US FDA and other national regulatory agencies for use in superficial bladder‐cancer treatment. The review found that BCG treatment was effective in preventing cancer recurrence following surgery. Further studies into making treatment more effective are needed.
Men with advanced prostate cancer and painful bone metastases are a difficult group of patients to treat. Data from recent randomised trials of chemotherapy suggest an improvement in overall survival, pain relief, and quality of life with this form of therapy. Side effects are common and can be severe. Chemotherapy offers a treatment option for men with hormone‐refractory prostate cancer (HRPC), but the decision to treat should be carefully considered by the patient and clinician. More studies are needed to find new and better agents.
Early breast cancer can be removed by surgery, and for most women the chance of the cancer returning (recurrence) is small. In some women however, the cancerreturns in the same area. Chemotherapy (anti‐cancer drugs) can be used together with other treatments, such as surgery or radiation therapy, to try to treat recurringcancer and improve survival. The review found that few trials have been performed to investigate its effectiveness. There is currently not enough evidence that adding chemotherapy to other treatments helps to treat the recurring cancer or to improve survival. However, chemotherapy may be an option, and further trials are underwa.
Ovarian cancer is the sixth most common cancer among women. Epithelial ovariancancer is a disease in which malignant cells form in the tissue covering the ovary. It accounts for about 90% of ovarian cancers., the remaining 10% arise from germ cells and the sex cord and stroma of the ovary. Women with epithelial ovariancancer that has returned after primary surgery (recurrent disease) may need secondary surgery to remove all or part of the cancer. The option of surgery (debulking or cytoreductive surgery) is currently offered to a select group of women with recurrent ovarian cancer. It is important to ascertain whether this surgery helps women with recurrent disease to survive for longer than if they only got chemotherapy.
In rectal cancer patients, local control is improved by administering radiotherapy (RT) before surgery. Recently, studies have combined preoperative RT with chemotherapy aiming to further improve local control. This review compared preoperative RT with preoperative chemoradiation (CRT) in patients with stage II and III rectal cancer.
Cancer of the vulva is mainly a disease of elderly women. Surgery involves removal of the tumour and surrounding lymph nodes, occasionally followed by radiotherapy. Although survival rates are high if the tumour is found early enough, removal of the lymph nodes causes odema (swelling), particularly in the legs. Wound healing and psychosexual problems are also common. While radiotherapy may be effective in the short term, there is not enough evidence from trials to show that it is as effective as surgery in preventing tumour regrowth in the lymph nodes of the groin.
Secondary cancer tumours (metastases) located in bone tissue can cause high levels of pain and distress in patients with terminal cancer. Radiotherapy is used commonly to provide pain relief, however, the precise effectiveness of radiotherapy may be unclear. The objectives of this systematic review were to assess pain relief from localised bone metastases by radiotherapy, and from generalised metastases in other parts of the body by radiotherapy or radioisotopes. Several important findings were made. One patient in four will get complete pain relief after one month's radiotherapy treatment, while one patient in three will experience at least 50% relief after one month. Overall, radiotherapy produced at least 50% pain relief in a little less than half of patients at some other point during the study. Patients receiving radiotherapy plus strontium reported higher levels of well‐being than those receiving radiotherapy plus placebo. Radioisotopes alone were found to produce a similar extent of relief to that provided by radiotherapy. The results confirm that both external irradiation and radioisotopes can provide effective pain relief for painful bone metastases. This is a significant finding given that analgesic drug regimes are often ineffective for this type of pain. Limitations of the review include poor reporting in the included studies about adverse effects of radiotherapy, e.g. vomiting and diarrhoea, and about the speed with which relief occurs or its duration.
At present, doctors are not sure whether women with early cervical cancer who have had their womb and pelvic lymph nodes removed should be given radiotherapy. If the woman has a combination of certain risk factors which put her at high risk of having a recurrence of her cancer, doctors often think that it would be a good idea to give her radiotherapy. However, radiotherapy has never been shown to improve overall survival for these women and the combination of surgery and radiotherapy increases the risk of side‐effects and complications. We searched for all the available RCTs that assessed whether radiotherapy (with or without chemotherapy) could improve survival in these women.
Patients who die of colorectal cancer usually die from, or at least with, liver metastases. On the other hand, isolated liver metastases can, on occasion, be resected with a chance of cure, if metastatic disease is not present elsewhere. After liver resection is performed for colorectal cancer metastases, the most common site of treatment failure is in the remaining liver. For that reason it has been proposed that chemotherapy be given in the hepatic artery after surgery to treat microscopic disease in the remaining liver.
Transurethral resection (TUR) is the usual treatment method for patients who, when examined with a cystoscope, are found to have abnormal growths on the urothelium (stage Ta) and/or in the lamina propria (stage T1). However post‐operation tumour recurrence is a major clinical problem. Intravesical Bacillus Calmette‐Guérin or epirubicin following surgery are therefore often used to try to prevent the cancerrecurrence. This review found that intravesical Bacillus Calmette‐Guérin is more efficacious than epirubicin to prevent cancer recurrence. However, Bacillus Calmette‐Guérin appears to induce greater local and systemic adverse effects than epirubicin.
Early stage cervical cancer of the common type, squamous cell carcinoma, has the same prognosis after primary surgery or radiotherapy. For cervical cancer of the glandular cell type (adenocarcinoma) type we recommend surgery. Second best alternative for patients unfit for surgery is chemoradiation. For patients with suspected positive lymph nodes chemoradiation is probably the first choice
Endometrial cancer is cancer arising from the lining of the womb. Most women with endometrial cancer are diagnosed when their tumour is still confined to the body of the womb. However, about 10% of women with endometrial cancer are diagnosed when the disease is already at an advanced stage. The latter group of patients tend to have much poorer survival.
Ovarian cancer frequently presents at an advanced stage so it may not be possible to remove all tumours during surgery. Several cycles of chemotherapy are generally given after primary surgery. Secondary surgery, performed after a few cycles of chemotherapy before further cycles of chemotherapy, is called interval debulking surgery (IDS). This review compares the survival of patients with advanced epithelial ovarian cancer, who had IDS performed between cycles of chemotherapy after primary surgery with survival of patients who had conventional treatment (primary debulking surgery and adjuvant chemotherapy). It found similar survival rates in patients who did and did not receive IDS. No adequate information regarding adverse effects was available. Data on quality of life (QoL) of the patients were also inconclusive.
High grade glioma is a rapidly progressive form of brain tumour. Standard therapy involves the use of surgery (either biopsy or resection) and radiotherapy plus or minus temozolomide. Chemotherapy was not previously used due to concerns over efficacy and high risks of side effects.
These women have a poor prognosis. Giving extra drugs seems to reduce disease progression by a small amount. However, it does not seem to allow women to live longer. Also, more chemotherapy seems to cause a greater amount of serious short‐term side effects. Paclitaxel or platinum drugs may be better than other drugs. The effect of drug therapy on long‐term side effects, control of symptoms and quality of life (QOL) was poorly studied. Also, no studies compared drug therapy with hormone therapy.
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