Influence of Combined General and Epidural Anesthesia on Cancer Prognosis: A Meta-analysis_Chinese Journal of Evidence-Based Medicine

Authors：

CHANG Xiaoli , ZHU Dan ,  REN Xuli

Department of Anesthesiology, the First Affiliated Hospital, China Medical University, Shenyang 110001, China;

Corresponding author：

REN Xuli, Email: hwl1998@yahoo.com

Keywords：

General anesthesia; Epidural anesthesia; Recurrence of cancer; Metastasis of cancer; Meta-analysis; Systematic review

DOI：

10.7507/1672-2531.20110159

Video：

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Objective 　To evaluate the influence of combined general and epidural anesthesia on the prognosis of patients undergoing cancer surgery.
Methods 　Such database as PubMed, OVID, EBSCO, The Cochrane Library and CNKI were searched, and other relevant journals and references of the included literature were also hand searched from 1986 to 2011. Two evaluators independently screened the studies in accordance with the inclusion and exclusion criteria, extracted the data and assessed the methodology quality. RevMan 5.0 software was used for meta-analyses.
Results 　Seven studies involving 2 513 patients were included. The results of meta-analyses showed that compared with the single general anesthesia, the combined general and epidural anesthesia had no significant differences in postoperative recurrence and metastasis rate (OR=0.71, 95%CI 0.44 to 1.17, P=0.18). Based on the following four factors i.e. category of cancer, time of follow-up, having preoperative metastais or not, and patients’ age, the sensitivity analysis showed significant differences in the postoperative recurrence and metastasis rate between the two anesthesia methods were found in the group of patients at or above 64 years old and the group with follow-up equal to or less than two years (OR=1.46, 95%CI 1.00 to 2.14, P=0.05; OR=1.55, 95%CI 1.06 to 2.26, P=0.02; respectively). Nevertheless, there was no significant difference in the groups of patients with colorectal cancer or without preoperative metastasis (OR=1.00, 95%CI 0.62-1.61, P=0.99; OR=1.26, 95%CI 0.86 to 1.86, P=0.23; respectively).
Conclusion 　Compared with single general anesthesia, the combined general and epidural anesthesia cannot reduce the recurrence and metastasis rate for cancer patients, and has no marked improvement in prognosis of patients with colorectal cancer or without preoperative metastasis, but it obviously decreases the probability of forward recurrence and metastasis for the patients at or above 64 years old and the patients with follow-up equal to or less than two years.

Citation： CHANG Xiaoli,ZHU Dan,REN Xuli,LV Huangwei. Influence of Combined General and Epidural Anesthesia on Cancer Prognosis: A Meta-analysis. Chinese Journal of Evidence-Based Medicine, 2011, 11(8): 954-959. doi: 10.7507/1672-2531.20110159 Copy

1.	Sessler DI. Does regional analgesia reduce the risk of cancer recurrence? A hypothesis. Eur J Cancer Prev , 2008, 17(3): 269-272.
2.	Gupta GP, Massague J. Cancer metastasis: Building a framework. Cell , 2006, 127(17): 679-695.
3.	Hedley BD, Chambers AF. Tumor dormancy and metastasis. Adv Cancer Res , 2009, 102: 67-101.
4.	Jadad AR, Moore RA, Carroll D, et al . Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials , 1996, 17(1): 1-12.
5.	Gottschalk A, Ford JG, Regelin CC, et al . Association between epidural analgesia and cancer recurrence after colorectal cancer surgery. Anesthesiology , 2010, 113(1): 27-34.
6.	Exadaktylos AK, Buggy DJ, Moriarty DC, et al . Can Anesthetic Technique for Primary Breast Cancer Surgery Affect Recurrence or Metastasis? Anesthesiology , 2006, 105(4): 660-664.
7.	Tsui BC, Rashiq S, Schopflocher D, et al . Epidural anesthesia and cancer recurrence rates after radical Prostatectomy. Can J Anesth , 2010, 57(2): 107-112.
8.	Christopherson R, James KE, Tableman M, et al . Long-Term Survival After Colon Cancer Surgery: A Variation Associated with Choice of Anesthesia. Anesth Analg , 2008, 107(1): 325-332.
9.	Wuethrich PY, Hsu Schmitz SF, Kessler TM, et al . Potential Influence of the Anesthetic Technique Used during Open Radical Prostatectomy on Prostate Cancer-related Outcome. Anesthesiology , 2010, 113(3): 570-6.
10.	Luo CF, Su B. Analgesic technique for primary colon cancer surgery doesn’t affect cancer recurrence. Anesth Analg , 2010, 14AP8-4.
11.	Biki B, Mascha E, Moriarty DC, et al . Anesthetic technique for radical prostatectomy surgery affects cancer recurrence a retrospective analysis. Anesthesiology , 2008, 109(2): 180-187.
12.	Sessler DI, Ben ES, Mascha EJ, et al . General anaesthesia vs local anaesthesia: an ongoing story. Br J Anaesth , 2009, 103(6): 785-789.
13.	Snyder GL, Greenberg S. Effect of anaesthetic technique and other perioperative factors on cancer recurrence. Br J Anaesth , 2010, 105(2): 106-115.
14.	Vila H Jr, Liu J, Kavasmaneck D. Paravertebral block: new benefits from an old procedure. Curr Opin Anaesthesiol , 2007, 20(4): 316-318.
15.	Gottschalk A, Sharma S, Ford J, et al . The role of the perioperative period in recurrence after cancer surgery. Anesth Analg , 2010, 110(5): 1636-1643.
16.	Shakhar G, Ben-Eliyahu S. Potential Prophylactic Measures Against Postoperative Immuno suppression: Could They Reduce Recurrence Rates in Oncological Patients. Annals of Surgical Oncology , 2003, 10(8): 972-992.
17.	Forget P, De Kock M. Could anaesthesia, analgesia and sympathetic modulation affect neoplasic recurrence after surgery? A systematic review centred over the modulation of natural killer cells activity. Ann Fr Anesth Reanim , 2009, 28(9): 751-768.
18.	Moss J, Israel RJ. Effects of Anesthetics on Cancer Recurrence. J Clin Onco , 2009, 27(25): e89.
19.	Curatolo, Michele. Adding regional analgesia to general anaesthesia: increase of risk or improved outcome? Eur J Cancer Prev , 2010, 27(7): 586-591.
20.	Singleton PA, Moss J. Effect of perioperative opioids on cancer recurrence: a hypothesis. Future Oncol , 2010, 6(8): 1237-1242.
21.	Frank E, Sood OP, Torjman M, et al . Postoperative epidural analgesia following radical retropubic prostatectomy: outcome assessment. J Surg Oncol , 1998, 67(2): 117-120.
22.	Freedland SJ, Humphreys EB, Mangold LA, et al . Risk of prostate cancer-specific mortality following biochemical recurrence after radical prostatectomy. JAMA , 2005, 294: 433-439.
23.	Biki B, Mascha E, Moriarty DC, et al . Anesthetic technique for radical prostatectomy surgery affects cancer recurrence: a retrospective analysis. Anesthesiology , 2008, 109(2): 180-187.
24.	Exadaktylos AK, Buggy DJ, Moriarty DC, Mascha E, Sessler DI. Can anesthetic technique for primary breast cancer surgery affect recurrence or metastasis? Anesthesiology , 2006, 105: 660-664.
25.	Forget P, Vandenhende J, Berliere M, et al . Do intraoperative analgesics influence breast cancer recurrence after mastectomy? A retrospective analysis. Anesth Analg , 2010, 110: 1630-1635.
26.	Gupta K, Kshirsagar S, Chang L, et al . Morphine stimulates angiogenesis by activating proangiogenic and survival-promoting signaling and promotes breast tumor growth. Clin Cancer Res , 2002, 62: 4491-4498.
27.	Sessler DI, Ben ES, Mascha EJ, et al . Can regional analgesia reduce the risk of recurrence after breast cancer? Methodology of a multicenter randomized trial. Contemp Clin Trials , 2008, 29: 517-526.
28.	Soerjomataram I, Louwman MW, Ribot JG, et al . An overview of prognostic factors for long term survivors of breast cancer. Breast Cancer Res Treat , 2008, 107(4): 309-330.
29.	Brian M. Parker, MD. Anesthetics and anesthesia techniques: Impacts on perioperative management and postoperative outcomes. Cleveland Clinic Journal of Medicine , 2006, 73: SUPPLEMENT 1.
30.	Rodgers A, Walker N, Schug S, et al . Reduction of postoperative mortality, morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. Br J Anaesth , 2000, 321(3): 1493.
31.	Bovill JG. Surgery for Cancer: Does Anesthesia Matter? Anesth Analg , 2010, 110: 1524-1526.
32.	Kurosawa S, Kato M. Anesthetics, immune cells, and immune responses. J Anesth , 2008, 22: 263-277.
33.	O'Riain SC, Buggy DJ, Kerin MJ, et al . Inhibition of the stress response to breast cancer surgery by regional anesthesia and analgesia does not affect vascular endothelial growth factor and prostaglandin E2. Anesth Analg , 2005, 100(1): 244-249.
34.	Munoz M, Rosso M, Casinello F, et al . Paravertebral anesthesia: how substance P and the NK-1 receptor could be involved in regional block and breast cancer recurrence. Breast Cancer Res Treat , 2010, 122(2): 601-603.
35.	Benish M, Ben-Eliyahu S. Surgery as a Double-Edged Sword: A Clinically Feasible Approach to Overcome the Metastasis-Promoting Effects of Surgery by Blunting Stress and Prostaglandin Responses. Cancers , 2010, 2(5): 1929-1951.
36.	Wada H, Seki S, Takahashi T, et al . Combined spinal and general anesthesia attenuates liver metastasis by preserving TH1/TH2 cytokine balance. Anesthesiology , 2007, 106(3): 499-506.
37.	Looney M, Doran P, Buggy DJ. Effect of anesthetic technique on serum vascular endothelial growth factor C and transforming growth factor β in women undergoing anesthesia and surgery for breast cancer. Anesthesiology , 2010, 113(5): 1118-1125.
38.	Weckermann D, Polzer B, Ragg T, et al . Perioperative activation of disseminated tumor cells in bone marrow of patients with prostate cancer. J Clin Oncol , 2009, 27(10): 1549-1556.
39.	Deegan CA, Murray D, Doran P, et al . Anesthetic technique and the cytokine and matrix metalloproteinase response to primary breast cancer surgery. Reg Anesth Pain Med, 2010, 35(6): 490-495.
40.	Jeremy B. Swann Mark J. Smyth. Immune surveillance of tumors. Clin Invest , 2010, 117(5): 1137-1146.
41.	DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials , 1986, 7(3): 177-188.
42.	LeLorier J, Gregoire G, Benhaddad A, et al . Discrepancies between meta-analyses and subsequent large randomized, controlled trials. N Engl J Med , 1997, 337(8): 536-542.

1. Sessler DI. Does regional analgesia reduce the risk of cancer recurrence? A hypothesis. Eur J Cancer Prev , 2008, 17(3): 269-272.
2. Gupta GP, Massague J. Cancer metastasis: Building a framework. Cell , 2006, 127(17): 679-695.
3. Hedley BD, Chambers AF. Tumor dormancy and metastasis. Adv Cancer Res , 2009, 102: 67-101.
4. Jadad AR, Moore RA, Carroll D, et al . Assessing the quality of reports of randomized clinical trials: is blinding necessary? Control Clin Trials , 1996, 17(1): 1-12.
5. Gottschalk A, Ford JG, Regelin CC, et al . Association between epidural analgesia and cancer recurrence after colorectal cancer surgery. Anesthesiology , 2010, 113(1): 27-34.
6. Exadaktylos AK, Buggy DJ, Moriarty DC, et al . Can Anesthetic Technique for Primary Breast Cancer Surgery Affect Recurrence or Metastasis? Anesthesiology , 2006, 105(4): 660-664.
7. Tsui BC, Rashiq S, Schopflocher D, et al . Epidural anesthesia and cancer recurrence rates after radical Prostatectomy. Can J Anesth , 2010, 57(2): 107-112.
8. Christopherson R, James KE, Tableman M, et al . Long-Term Survival After Colon Cancer Surgery: A Variation Associated with Choice of Anesthesia. Anesth Analg , 2008, 107(1): 325-332.
9. Wuethrich PY, Hsu Schmitz SF, Kessler TM, et al . Potential Influence of the Anesthetic Technique Used during Open Radical Prostatectomy on Prostate Cancer-related Outcome. Anesthesiology , 2010, 113(3): 570-6.
10. Luo CF, Su B. Analgesic technique for primary colon cancer surgery doesn’t affect cancer recurrence. Anesth Analg , 2010, 14AP8-4.
11. Biki B, Mascha E, Moriarty DC, et al . Anesthetic technique for radical prostatectomy surgery affects cancer recurrence a retrospective analysis. Anesthesiology , 2008, 109(2): 180-187.
12. Sessler DI, Ben ES, Mascha EJ, et al . General anaesthesia vs local anaesthesia: an ongoing story. Br J Anaesth , 2009, 103(6): 785-789.
13. Snyder GL, Greenberg S. Effect of anaesthetic technique and other perioperative factors on cancer recurrence. Br J Anaesth , 2010, 105(2): 106-115.
14. Vila H Jr, Liu J, Kavasmaneck D. Paravertebral block: new benefits from an old procedure. Curr Opin Anaesthesiol , 2007, 20(4): 316-318.
15. Gottschalk A, Sharma S, Ford J, et al . The role of the perioperative period in recurrence after cancer surgery. Anesth Analg , 2010, 110(5): 1636-1643.
16. Shakhar G, Ben-Eliyahu S. Potential Prophylactic Measures Against Postoperative Immuno suppression: Could They Reduce Recurrence Rates in Oncological Patients. Annals of Surgical Oncology , 2003, 10(8): 972-992.
17. Forget P, De Kock M. Could anaesthesia, analgesia and sympathetic modulation affect neoplasic recurrence after surgery? A systematic review centred over the modulation of natural killer cells activity. Ann Fr Anesth Reanim , 2009, 28(9): 751-768.
18. Moss J, Israel RJ. Effects of Anesthetics on Cancer Recurrence. J Clin Onco , 2009, 27(25): e89.
19. Curatolo, Michele. Adding regional analgesia to general anaesthesia: increase of risk or improved outcome? Eur J Cancer Prev , 2010, 27(7): 586-591.
20. Singleton PA, Moss J. Effect of perioperative opioids on cancer recurrence: a hypothesis. Future Oncol , 2010, 6(8): 1237-1242.
21. Frank E, Sood OP, Torjman M, et al . Postoperative epidural analgesia following radical retropubic prostatectomy: outcome assessment. J Surg Oncol , 1998, 67(2): 117-120.
22. Freedland SJ, Humphreys EB, Mangold LA, et al . Risk of prostate cancer-specific mortality following biochemical recurrence after radical prostatectomy. JAMA , 2005, 294: 433-439.
23. Biki B, Mascha E, Moriarty DC, et al . Anesthetic technique for radical prostatectomy surgery affects cancer recurrence: a retrospective analysis. Anesthesiology , 2008, 109(2): 180-187.
24. Exadaktylos AK, Buggy DJ, Moriarty DC, Mascha E, Sessler DI. Can anesthetic technique for primary breast cancer surgery affect recurrence or metastasis? Anesthesiology , 2006, 105: 660-664.
25. Forget P, Vandenhende J, Berliere M, et al . Do intraoperative analgesics influence breast cancer recurrence after mastectomy? A retrospective analysis. Anesth Analg , 2010, 110: 1630-1635.
26. Gupta K, Kshirsagar S, Chang L, et al . Morphine stimulates angiogenesis by activating proangiogenic and survival-promoting signaling and promotes breast tumor growth. Clin Cancer Res , 2002, 62: 4491-4498.
27. Sessler DI, Ben ES, Mascha EJ, et al . Can regional analgesia reduce the risk of recurrence after breast cancer? Methodology of a multicenter randomized trial. Contemp Clin Trials , 2008, 29: 517-526.
28. Soerjomataram I, Louwman MW, Ribot JG, et al . An overview of prognostic factors for long term survivors of breast cancer. Breast Cancer Res Treat , 2008, 107(4): 309-330.
29. Brian M. Parker, MD. Anesthetics and anesthesia techniques: Impacts on perioperative management and postoperative outcomes. Cleveland Clinic Journal of Medicine , 2006, 73: SUPPLEMENT 1.
30. Rodgers A, Walker N, Schug S, et al . Reduction of postoperative mortality, morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. Br J Anaesth , 2000, 321(3): 1493.
31. Bovill JG. Surgery for Cancer: Does Anesthesia Matter? Anesth Analg , 2010, 110: 1524-1526.
32. Kurosawa S, Kato M. Anesthetics, immune cells, and immune responses. J Anesth , 2008, 22: 263-277.
33. O'Riain SC, Buggy DJ, Kerin MJ, et al . Inhibition of the stress response to breast cancer surgery by regional anesthesia and analgesia does not affect vascular endothelial growth factor and prostaglandin E2. Anesth Analg , 2005, 100(1): 244-249.
34. Munoz M, Rosso M, Casinello F, et al . Paravertebral anesthesia: how substance P and the NK-1 receptor could be involved in regional block and breast cancer recurrence. Breast Cancer Res Treat , 2010, 122(2): 601-603.
35. Benish M, Ben-Eliyahu S. Surgery as a Double-Edged Sword: A Clinically Feasible Approach to Overcome the Metastasis-Promoting Effects of Surgery by Blunting Stress and Prostaglandin Responses. Cancers , 2010, 2(5): 1929-1951.
36. Wada H, Seki S, Takahashi T, et al . Combined spinal and general anesthesia attenuates liver metastasis by preserving TH1/TH2 cytokine balance. Anesthesiology , 2007, 106(3): 499-506.
37. Looney M, Doran P, Buggy DJ. Effect of anesthetic technique on serum vascular endothelial growth factor C and transforming growth factor β in women undergoing anesthesia and surgery for breast cancer. Anesthesiology , 2010, 113(5): 1118-1125.
38. Weckermann D, Polzer B, Ragg T, et al . Perioperative activation of disseminated tumor cells in bone marrow of patients with prostate cancer. J Clin Oncol , 2009, 27(10): 1549-1556.
39. Deegan CA, Murray D, Doran P, et al . Anesthetic technique and the cytokine and matrix metalloproteinase response to primary breast cancer surgery. Reg Anesth Pain Med, 2010, 35(6): 490-495.
40. Jeremy B. Swann Mark J. Smyth. Immune surveillance of tumors. Clin Invest , 2010, 117(5): 1137-1146.
41. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials , 1986, 7(3): 177-188.
42. LeLorier J, Gregoire G, Benhaddad A, et al . Discrepancies between meta-analyses and subsequent large randomized, controlled trials. N Engl J Med , 1997, 337(8): 536-542.

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Influence of Combined General and Epidural Anesthesia on Cancer Prognosis: A Meta-analysis

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