Association of Perioperative Use of Epidural Analgesia with Disease Free Survival in Epithelial Ovarian Cancer: A Retrospective Cohort Observational Study with Propensity Score Matched Analysis
-
Kalpana Balakrishnan
,
Punitha Chockalingam
,
Thendral Ramasamy
,
Meenakshi Venkateswaran
,
Madhupriya Sundaram
,
Veluswami Sridevi
Abstract
Background: Recurrence is common after surgery for epithelial ovarian cancer and is multifactorial. Perioperative factors affecting stress and inflammation have an influence on immunity and thus cancer recurrence. The effect of peri-operative epidural anesthesia has been quoted to be beneficial by decreasing stress. A retrospective analysis of perioperative Epidural analgesia use (EA) was compared to general anesthesia (GA) without epidural, with disease free survival (DFS)as the outcome.
Methods: We did a retrospective observational study of patients with epithelial ovarian malignancy who had undergone surgery between 2013 and 2017. Cohorts were primarily divided based on receipt of epidural analgesia. Perioperative patient, anesthetic, and tumor related data were collected. The aim was to estimate the association of epidural analgesia with disease free survival (DFS). To prevent bias due to skewed covariate distribution propensity score match was done matching all covariates.
Results: We had 312 patients with age ranging from 18 to 77. The median DFS in months was 32.73±25.6 for the entire cohort while it was 54.81±28.69 for the GA group and 27.23±21.84 for EA group. After PSM median DFS was 35.33 for the full cohort and it was 46 and 34 months for the GA and EA groups, respectively. Multivariate Cox regression analysis demonstrated that only patients who were undergoing primary surgery had survival advantage (P<0.013). Perioperative epidural analgesia was not associated with survival benefit (P=0.480).
Conclusion: Perioperative use of epidural analgesia did not offer survival benefit in epithelial ovarian cancer as measured by disease free survival.
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[14] Pei L, Tan G, Wang L, Guo W, Xiao B, Gao X, et al. Comparison of combined general-epidural anesthesia with general anesthesia effects on survival and cancer recurrence: a meta-analysis of retrospective and prospective studies. PloS one. 2014;9(12):e114667.
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[17] Tseng JH, Cowan RA, Afonso AM, Zhou Q, Iasonos A, Ali N, et al. Perioperative epidural use and survival outcomes in patients undergoing primary debulking surgery for advanced ovarian cancer. Gynecol Oncol. 2018; 151(2):287–93.
[18] Capmas P, Billard V, Gouy S, Lhommé C, Pautier P, Morice P, et al. Impact of epidural analgesia on survival in patients undergoing complete cytoreductive surgery for ovarian cancer. Anticancer Res. 2012; 32(4):1537–42.
[19] Lacassie HJ, Cartagena J, Brañes J, Assel M, Echevarría GC. The relationship between neuraxial anesthesia and advanced ovarian cancer-related outcomes in the Chilean population. Anesth Analg. 2013; 117(3):653–60.
[20] Grandhi RK, Lee S, Abd-Elsayed A. The Relationship Between Regional Anesthesia and Cancer: A Metaanalysis. Ochsner J. 2017;17(4):345–61.
[21] Lee ZX, Ng KT, Ang E, Wang CY, Binti Shariffuddin II. Effect of perioperative regional anesthesia on cancer recurrence: A meta-analysis of randomized controlled trials. Int J Surg. 2020; 82:192-199.
[22] Sessler DI, Ben-Eliyahu S, Mascha EJ, Parat M-O, Buggy DJ. Can regional analgesia reduce the risk of recurrence after breast cancer? Methodology of a multicenter randomized trial. Contemp Clin Trials. 2008; 29(4):517–26.
[23] Xu ZZ, Li HJ, Li MH, Huang SM, Li X, Liu QH, et al. Epidural Anesthesia–Analgesia and Recurrence-free Survival after Lung Cancer Surgery: A Randomized Trial. Anesthesiology. 2021; 135(3):419-432.
[24] Du Y-T, Li Y-W, Zhao B-J, Guo X-Y, Feng Y, Zuo M-Z, et al. Long-term Survival after Combined Epidural–General Anesthesia or General Anesthesia Alone: Follow-up of a Randomized Trial. Anesthesiology. 2021; 135(2):233-245.
[25] May T, Comeau R, Sun P, Kotsopoulos J, Narod SA, Rosen B, et al. A Comparison of Survival Outcomes in Advanced Serous Ovarian Cancer Patients Treated with Primary Debulking Surgery Versus Neoadjuvant Chemotherapy. Int J Gynecol Cancer. 2017; 27(4):668-674.
[26] Ditto A, Leone Roberti Maggiore U, Bogani G, Martinelli F, Chiappa V, Evangelista MT, et al. Predictive factors of recurrence in patients with early-stage epithelial ovarian cancer. Int J Gynaecol Obstet. 2019; 145(1):28–33.
[27] Okunade KS, Adejimi AA, Ohazurike EO, Salako O, Osunwusi B, Adenekan MA, et al. Predictors of Survival Outcomes After Primary Treatment of Epithelial Ovarian Cancer in Lagos, Nigeria. JCO Glob Oncol. 2021; 7:89–98.
[28] Amin AT, Ahmed BM, Refaat A, Sileem SA, Khallaf SM, Amin AT, et al. Primary Debulking Surgery for Stage III Epithelial Ovarian Cancer Has a Better Outcome Than Neoadjuvant Chemotherapy Followed by Interval Debulking Surgery. J Cancer Therapy. 2020;11(3):142–53.
[29] Georgeena P, Rajanbabu A, Vijaykumar DK, Pavithran K, Sundaram KR, Deepak KS, et al. Surgical treatment pattern and outcomes in epithelial ovarian cancer patients from a cancer institute in Kerala, India. Ecancermedicalscience. 2016; 10:619.
[30] Buggy DJ, Riedel B, Sessler DI. Can anaesthetic technique influence cancer outcome? The next steps…. Br J Anaesth. 2021; 127(1):5-7.
[2] Divatia JV, Ambulkar R. Anesthesia and cancer recurrence: What is the evidence? J Anaesthesiol Clin Pharmacol. 2014; 30(2):147-50.
[3] Jain P, Balkrishanan K, Nayak S, Gupta N, Shah S. Onco-Anaesthesiology and palliative medicine: Opportunities and challenges. Indian J Anaesth. 2021; 65(1):29-34.
[4] Anesthesia and cancer recurrence - UpToDate [Internet]. Available from: https://www.uptodate.com/contents/anesthesia-and-cancer-recurrence
[5] Kim R. Effects of surgery and anesthetic choice on immunosuppression and cancer recurrence. J Transl Med. 2018;16(1):8.
[6] Das J, Kumar S, Khanna S, Mehta Y. Are we causing the recurrence-impact of perioperative period on long-term cancer prognosis: Review of current evidence and practice. J Anaesthesiol Clin Pharmacol. 2014; 30(2):153-9.
[7] Elias KM, Kang S, Liu X, Horowitz NS, Berkowitz RS, Frendl G. Anesthetic Selection and Disease-Free Survival Following Optimal Primary Cytoreductive Surgery for Stage III Epithelial Ovarian Cancer. Ann Surg Oncol. 2015; 22(4):1341-8.
[8] Kuo CN, Pan JJ, Huang YW, Tsai HJ, Chang WC. Association between nonsteroidal anti-inflammatory drugs and colorectal cancer: A population-based case-control study. Cancer Epidemiol Biomarkers Prev. 2018; 27(7):737-745.
[9] Smyth MJ, Godfrey DI, Trapani JA. A fresh look at tumor immunosurveillance and immunotherapy. Nat Immunol. 2001; 2(4):293-9.
[10] Forget P, Bentin C, Machiels JP, Berliere M, Coulie PG, De Kock M. Intraoperative use of ketorolac or diclofenac is associated with improved disease-free survival and overall survival in conservative breast cancer surgery. Br J Anaesth. 2014; 113 Suppl:i82-7.
[11] Merritt MA, Rice MS, Barnard ME, Hankinson SE, Matulonis UA, Poole EM, et al. Pre-diagnosis and post-diagnosis use of common analgesics and ovarian cancer prognosis (NHS/NHSII): a cohort study. Lancet Oncol. 2018; 19(8):1107–16.
[12] Amato A, Pescatori M. Perioperative blood transfusions for the recurrence of colorectal cancer. Cochrane Database Syst Rev. 2006; 2006(1):CD005033.
[13] Weng M, Chen W, Hou W, Li L, Ding M, Miao C. The effect of neuraxial anesthesia on cancer recurrence and survival after cancer surgery: an updated meta-analysis. Oncotarget. 2016; 7(12):15262–73.
[14] Pei L, Tan G, Wang L, Guo W, Xiao B, Gao X, et al. Comparison of combined general-epidural anesthesia with general anesthesia effects on survival and cancer recurrence: a meta-analysis of retrospective and prospective studies. PloS one. 2014;9(12):e114667.
[15] Lin L, Liu C, Tan H, Ouyang H, Zhang Y, Zeng W. Anaesthetic technique may affect prognosis for ovarian serous adenocarcinoma: a retrospective analysis. Br J Anaesth. 2011; 106(6):814–22.
[16] de Oliveira GSJ, Ahmad S, Schink JC, Singh DK, Fitzgerald PC, McCarthy RJ. Intraoperative neuraxial anesthesia but not postoperative neuraxial analgesia is associated with increased relapse-free survival in ovarian cancer patients after primary cytoreductive surgery. Reg Anesth Pain Med. 2011;36(3):271–7.
[17] Tseng JH, Cowan RA, Afonso AM, Zhou Q, Iasonos A, Ali N, et al. Perioperative epidural use and survival outcomes in patients undergoing primary debulking surgery for advanced ovarian cancer. Gynecol Oncol. 2018; 151(2):287–93.
[18] Capmas P, Billard V, Gouy S, Lhommé C, Pautier P, Morice P, et al. Impact of epidural analgesia on survival in patients undergoing complete cytoreductive surgery for ovarian cancer. Anticancer Res. 2012; 32(4):1537–42.
[19] Lacassie HJ, Cartagena J, Brañes J, Assel M, Echevarría GC. The relationship between neuraxial anesthesia and advanced ovarian cancer-related outcomes in the Chilean population. Anesth Analg. 2013; 117(3):653–60.
[20] Grandhi RK, Lee S, Abd-Elsayed A. The Relationship Between Regional Anesthesia and Cancer: A Metaanalysis. Ochsner J. 2017;17(4):345–61.
[21] Lee ZX, Ng KT, Ang E, Wang CY, Binti Shariffuddin II. Effect of perioperative regional anesthesia on cancer recurrence: A meta-analysis of randomized controlled trials. Int J Surg. 2020; 82:192-199.
[22] Sessler DI, Ben-Eliyahu S, Mascha EJ, Parat M-O, Buggy DJ. Can regional analgesia reduce the risk of recurrence after breast cancer? Methodology of a multicenter randomized trial. Contemp Clin Trials. 2008; 29(4):517–26.
[23] Xu ZZ, Li HJ, Li MH, Huang SM, Li X, Liu QH, et al. Epidural Anesthesia–Analgesia and Recurrence-free Survival after Lung Cancer Surgery: A Randomized Trial. Anesthesiology. 2021; 135(3):419-432.
[24] Du Y-T, Li Y-W, Zhao B-J, Guo X-Y, Feng Y, Zuo M-Z, et al. Long-term Survival after Combined Epidural–General Anesthesia or General Anesthesia Alone: Follow-up of a Randomized Trial. Anesthesiology. 2021; 135(2):233-245.
[25] May T, Comeau R, Sun P, Kotsopoulos J, Narod SA, Rosen B, et al. A Comparison of Survival Outcomes in Advanced Serous Ovarian Cancer Patients Treated with Primary Debulking Surgery Versus Neoadjuvant Chemotherapy. Int J Gynecol Cancer. 2017; 27(4):668-674.
[26] Ditto A, Leone Roberti Maggiore U, Bogani G, Martinelli F, Chiappa V, Evangelista MT, et al. Predictive factors of recurrence in patients with early-stage epithelial ovarian cancer. Int J Gynaecol Obstet. 2019; 145(1):28–33.
[27] Okunade KS, Adejimi AA, Ohazurike EO, Salako O, Osunwusi B, Adenekan MA, et al. Predictors of Survival Outcomes After Primary Treatment of Epithelial Ovarian Cancer in Lagos, Nigeria. JCO Glob Oncol. 2021; 7:89–98.
[28] Amin AT, Ahmed BM, Refaat A, Sileem SA, Khallaf SM, Amin AT, et al. Primary Debulking Surgery for Stage III Epithelial Ovarian Cancer Has a Better Outcome Than Neoadjuvant Chemotherapy Followed by Interval Debulking Surgery. J Cancer Therapy. 2020;11(3):142–53.
[29] Georgeena P, Rajanbabu A, Vijaykumar DK, Pavithran K, Sundaram KR, Deepak KS, et al. Surgical treatment pattern and outcomes in epithelial ovarian cancer patients from a cancer institute in Kerala, India. Ecancermedicalscience. 2016; 10:619.
[30] Buggy DJ, Riedel B, Sessler DI. Can anaesthetic technique influence cancer outcome? The next steps…. Br J Anaesth. 2021; 127(1):5-7.
| Files | ||
| Issue | Vol 9 No 2 (2023): Spring |
|
| Section | Research Article(s) | |
| DOI | https://doi.org/10.18502/aacc.v9i2.12506 | |
| Keywords | ||
| Disease free survival Epidural analgesia Epithelial ovarian cancer General anaesthesia Survival analysis. | ||
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How to Cite
1.
Balakrishnan K, Chockalingam P, Ramasamy T, Venkateswaran M, Sundaram M, Sridevi V. Association of Perioperative Use of Epidural Analgesia with Disease Free Survival in Epithelial Ovarian Cancer: A Retrospective Cohort Observational Study with Propensity Score Matched Analysis. Arch Anesth & Crit Care. 2022;9(2):107-115.
