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Cancer rates are on the rise, and health services around the world are facing the growing challenge of providing effective but good value treatment. Over the last two decades, oesophageal cancer rates have increased by 50% across the world, and there were nearly half a million cases globally in 2008.
Currently, the standard treatment for resectable oesophageal cancer is chemotherapy or chemoradiotherapy, followed by surgery. At the moment this is the only curative option for this type of cancer and it is not without its problems—over half of patients experience pulmonary complications following surgery. Overall, mortality rates for this treatment are low, however post- operative complications mean longer stays in intensive care for patients, affecting their quality of life and increasing the financial burden on the healthcare system.
Biere et al’s recent paper in The Lancet investigated the possibility of using minimally invasive surgery for resectable oesophageal cancer (as opposed to open surgery), to ascertain whether it causes fewer pulmonary complications and improves post-operative quality of life. Minimally invasive surgery has been increasingly used over the last few years, but without solid evidence that it provides better treatment.
Biere at al’s paper is the first to fully investigate this issue. Biere et al’s study consisted of a randomised, open-label, multicentre trial spread across five European hospitals where oesophageal surgery was regularly performed. Surgeon bias was avoided where possible by ensuring surgeons had performed the procedure previously (a minimum of ten operations) and to an acceptable standard (the trials principle investigator visited all the sites to ensure operations were being performed to a standard). The primary outcome of the study was to assess whether minimally invasive surgery reduced post-operative pulmonary complications, while length of hospital stay was just one of a host of secondary outcomes that looked at whether quality of life improved.
The study assessed 115 patients randomly assigned to minimally invasive or open surgery. Results showed that minimally invasive surgery significantly reduced the incidence of pulmonary infection within two weeks of surgery (29% for open surgery, 9% for minimally invasive) and significantly reduced the length of patients’ stay in hospital (14 days for open surgery, 11 for minimally invasive). Other factors such as pain and blood loss were reduced, while quality of life scores were higher. This study therefore presents strong evidence that minimally invasive surgery provides improved short- term benefits for patients.
However, minimally invasive surgery is not the answer for all cancers of this type, with patients in this study having to meet strict inclusion criteria, thus lessening somewhat its potential impact as a new standard of care. The study’s impressive results do encourage the possibility of larger follow-up studies that could confirm the effectiveness of minimally invasive surgery with larger sample sizes and by using different populations.
Biere et al’s study has shown minimally invasive surgery for resectable cancer to bring about a better quality of life for post- operative patients. It goes a long way to confirming that for the right patients, minimally invasive surgery should be the standard of care.