Cochrane: How effective are initiatives that aim to speed up the diagnosis of brain tumours?

Cochrane Library | November 2020| How effective are initiatives that aim to speed up the diagnosis of brain tumours?

A recent Cochrane review has reviewed the question: How effective are initiatives that aim to speed up the diagnosis of brain tumours?

The review covers evidence that was available to January 2020, the reviewers identified d 115 studies that investigated the diagnosis of brain tumours, but as these did not meet all of their inclusion criteria, they were excluded. We found no studies with information about the cost of initiatives.

What this means
Currently, there is no evidence from good quality studies to inform patients, health professionals, or service planners about how to reduce the time to diagnosis of brain tumours. Nor is there any information on the cost of these initiatives. This review highlights the need for research in this area.

See also Cohrane overview

Review available from Cochrane

NICE Consultation: Skin cancer drug Nivolumab not cost effective for routine NHS use

NICE| November 2020| Skin cancer drug not cost effective for routine NHS use

The consultation has opened today (5 November 2020) and will close on Tuesday 24 November 2020

NICE has today (Thursday 5 November 2020) started a consultation on draft guidance which does not recommend the routine use of nivolumab (Opdivo; Bristol-Myers Squibb) as an option after surgery for some people with melanoma.

For the last 2 years nivolumab was recommended for use within the Cancer Drugs Fund as an option for the adjuvant treatment of completely resected melanoma in adults with lymph node involvement or metastatic disease.

This allowed for patients to access the drug while data on its effectiveness was collected to address significant clinical uncertainty and before it could be considered for routine commissioning.

However, the data from the Cancer Drugs Fund and the key clinical trial are still quite immature so it is uncertain if nivolumab increases the length of time people live, or by how much (overall survival). The cost-effectiveness estimates depend on assumptions about the long-term effect of nivolumab after treatment has stopped.  Because of the remaining uncertainty the committee was cautious when considering the most likely cost-effective estimates. 

Full details are from NICE

BMJ: Mortality due to cancer treatment delay: systematic review and meta-analysis

BMJ (2020) | Mortality due to cancer treatment delay: systematic review and meta-analysis| 371| m4087

A month long delay in treating cancer is associated with increased mortality for seven types of cancer: bladder, breast, colon, rectum, lung, cervical cancer, and head and neck cancer; delays longer than four weeks are even more detrimental.

For surgery, this is a 6-8% increase in the risk of death for every four week delay. This impact is even more marked for some radiotherapy and systemic indications, with a 9% and 13% increased risk of death for definitive head and neck radiotherapy and adjuvant systemic treatment for colorectal cancer, respectively.

The investigators acknowledge that their results reflect the impact of delay on large and expectedly heterogeneous populations with varying risks of recurrence. Therefore, these estimates are best used at a policy and planning level for modelling, rather than for individual risk prediction (Source: Hanna, et al. 2020).

Abstract

Objective To quantify the association of cancer treatment delay and mortality for each four week increase in delay to inform cancer treatment pathways.

Design Systematic review and meta-analysis.

Data sources Published studies in Medline from 1 January 2000 to 10 April 2020.

Eligibility criteria for selecting studies Curative, neoadjuvant, and adjuvant indications for surgery, systemic treatment, or radiotherapy for cancers of the bladder, breast, colon, rectum, lung, cervix, and head and neck were included. The main outcome measure was the hazard ratio for overall survival for each four week delay for each indication. Delay was measured from diagnosis to first treatment, or from the completion of one treatment to the start of the next. The primary analysis only included high validity studies controlling for major prognostic factors. Hazard ratios were assumed to be log linear in relation to overall survival and were converted to an effect for each four week delay. Pooled effects were estimated using DerSimonian and Laird random effect models.

Results The review included 34 studies for 17 indications (n=1 272 681 patients). No high validity data were found for five of the radiotherapy indications or for cervical cancer surgery. The association between delay and increased mortality was significant (P<0.05) for 13 of 17 indications. Surgery findings were consistent, with a mortality risk for each four week delay of 1.06-1.08 (eg, colectomy 1.06, 95% confidence interval 1.01 to 1.12; breast surgery 1.08, 1.03 to 1.13). Estimates for systemic treatment varied (hazard ratio range 1.01-1.28). Radiotherapy estimates were for radical radiotherapy for head and neck cancer (hazard ratio 1.09, 95% confidence interval 1.05 to 1.14), adjuvant radiotherapy after breast conserving surgery (0.98, 0.88 to 1.09), and cervix cancer adjuvant radiotherapy (1.23, 1.00 to 1.50). A sensitivity analysis of studies that had been excluded because of lack of information on comorbidities or functional status did not change the findings.

Conclusions Cancer treatment delay is a problem in health systems worldwide. The impact of delay on mortality can now be quantified for prioritisation and modelling. Even a four week delay of cancer treatment is associated with increased mortality across surgical, systemic treatment, and radiotherapy indications for seven cancers. Policies focused on minimising system level delays to cancer treatment initiation could improve population level survival outcomes.

Figure1
Visual abstract available from The BMJ, Hanna et al(2020)

Mortality due to cancer treatment delay: systematic review and meta-analysis

NICE: Osimertinib for treating EGFR T790M mutation-positive advanced non-small-cell lung cancer

NICE | October 2020 | Osimertinib for treating EGFR T790M mutation-positive advanced non-small-cell lung cancer

Evidence-based recommendations on osimertinib (Tagrisso) for treating epidermal growth factor receptor (EGFR) T790M mutation-positive locally advanced or metastatic non-small-cell lung cancer (NSCLC) in adults.

Osimertinib for treating EGFR T790M mutation-positive advanced non-small-cell lung cancer

Further information from NICE

NIHR: Breast cancer surgery is safer for older women than has been assumed

NIHR | October 2020 |Breast cancer surgery is safer for older women than has been assumed

Between 2013-2018 over 3000 women aged 70 or over with operable breast cancer were recruited to a NIHR- funded cohort study. The majority (83.4 %) of the women underwent surgery; with researchers tracking their progress for two years. One of the study’s key findings is that no deaths were attributable to surgery for breast cancer. According to the authors of the study, this suggests that surgery for breast cancer in women in this age group is perhaps safer than thought.

This study is part of a wider- Bridging the Age Gaps in Breast Cancer- project which aims to examine the characteristics and outcomes (survival, quality of life and adverse events) of women aged at least 70 years in the UK undergoing surgery for breast cancer.

Researchers found:

  • Fewer than one in five women (19.3%) had an adverse outcome, such as a dangerous blood clot (DVT) or wound pain.
  • a woman’s age predicted what surgery she would receive. The oldest women in the group were twice as likely to have a mastectomy than the youngest women (59.1% vs 29.9%). Younger women were more likely to have breast-conserving surgery, with less breast tissue removed. This may relate to the lack of screening in older women, so cancers tend to be found when they are bigger and women feel a lump.
  • older women were less likely to have lymph glands under the armpit removed (axillary surgery) than younger women (91.4% vs 98.6%). The aim of axillary surgery is to find out if the cancer has spread, and to remove any cancer in the axilla.
  • just 2.8% of the women in this study who had a mastectomy went on to have reconstructive sugery. This compares to one in five (20%) women overall in the UK.
  • quality of life was lower after surgery particularly for those who had more breast tissue removed as in mastectomy.
  • the risk of being unable to carry out some standard day to day tasks was higher after surgery.
Morgan, J. L., George, J., Holmes, G., Martin, C., Reed, M. W., Ward, S., … & Wyld, L. (2020). Breast cancer surgery in older women: outcomes of the Bridging Age Gap in Breast Cancer study. British Journal of Surgery.

Abstract

Background

Breast cancer surgery in older women is variable and sometimes non‐standard owing to concerns about morbidity. Bridging the Age Gap in Breast Cancer is a prospective multicentre cohort study aiming to determine factors influencing treatment selection and outcomes from surgery for older patients with breast cancer.

Methods

Women aged at least 70 years with operable breast cancer were recruited from 57 UK breast units between 2013 and 2018. Associations between patient and tumour characteristics and type of surgery in the breast and axilla were evaluated using univariable and multivariable analyses. Oncological outcomes, adverse events and quality‐of‐life (QoL) outcomes were monitored for 2 years.

Results

Among 3375 women recruited, surgery was performed in 2816 patients, of whom 24 with inadequate data were excluded. Sixty‐two women had bilateral tumours, giving a total of 2854 surgical events. Median age was 76 (range 70–95) years. Breast surgery comprised mastectomy in 1138 and breast‐conserving surgery in 1716 procedures. Axillary surgery comprised axillary lymph node dissection in 575 and sentinel node biopsy in 2203; 76 had no axillary surgery. Age, frailty, dementia and co‐morbidities were predictors of mastectomy. Age, frailty and co‐morbidity were significant predictors of no axillary surgery. The rate of adverse events was moderate, with no 30‐day mortality. Long‐term QoL and functional independence were adversely affected by surgery.

Conclusion

Breast cancer surgery is safe in women aged 70 years or more, with serious adverse events being rare and no mortality. Age, ill health and frailty all influence surgical decision‐making. Surgery has a negative impact on QoL and independence, which must be considered when counselling patients about choices.

Full paper BJS Breast cancer surgery in older women: outcomes of the Bridging Age Gap in Breast Cancer study

Further information on the project is available from the University of Sheffield’s Medical School Bridging the Age Gap in Breast Cancer

Lancet Oncology: UK cancer care threatened by government incompetence #covid19rftlks

Lancet Oncol (2020)|Published Online October 22, 2020 |https://doi.org/10.1016/
S1470-2045(20)30638-0

“The latest editorial in The Lancet Oncology sets out how cancer care in the UK is under threat

Cancer care cannot be put on hold; cancer care during the pandemic should not be beyond the capacity of the UK’s ostensibly world-class health system; and patients with suspected or prevalent cancer must not be denied timely access to care.

The effect of the first UK lockdown earlier this year on cancer screening, diagnosis, treatment, and supportive care has been widely documented. So far, an estimated 3 million people have missed cancer screenings, and between April and August, 2020, suspected cancer referrals were down 350000 compared with the same period in 2019. Delays in diagnosis and referral will indisputably lead to excess early cancer mortality; although exact numbers are uncertain, upwards of 60000 life-years could be lost during the next 5–10 years

Alongisde this the first lockdown also had an impact on research, with clinical trials in this area being halted.”

Read the full editorial in The Lancet Oncology

Cancer Research UK: GPs say elderly are not seeking help for potential cancer symptoms

Cancer Research UK| October 2020 | GPs say elderly are not seeking help for potential cancer symptoms

More than half (53 per cent) of GPs recently surveyed by Cancer Research mentioned that they were concerned that less older people are contacting them than before the pandemic. The leading cancer charity surveyed 1000 GPs online in September.

Respondents were asked to compare their experience prior to the pandemic.The findings also indicate a range of groups that GPs have concerns about during the pandemic these included:

  • patients with learning difficulties (40%)
  • those whose first language is not English (35%)
  • ethnic minorities (22%)
  • people from poorer backgrounds (23%)
  • those with existing health conditions (21%)

“I’m really concerned that less of my older patients are contacting the surgery and it’s worrying that colleagues across the UK are reporting this too. GP surgeries and hospitals are changing the way they do things to help keep patients and staff safe and people should be reassured that it’s safe to visit them. The first contact is likely to be by phone, and where appropriate a face to face will follow.

Dr Richard Roope, Cancer Research UK’s GP advisor

Read the full press release from Cancer Resarch UK