Does regional analgesia reduce risk for cancer progression when added to general anesthesia?


Based on a retrospective analysis of data from > 1,600 patients treated by radical prostatectomy at the Mayo Clinic, a newly published paper suggests that supplementing general anesthesia with regional (neuraxial) analgesia may lower risk for disease recurrence.

The new paper by Scavonetto et al. (along with a media release issued by the Mayo Clinic) is based on the concept that treatment of prostate cancer patients with systemic opioids post-surgery to control pain has an immunosuppressive effect, and could therefore promote tumour recurrence. Based on this risk, the authors set out to investigate whether the use of neuraxial analgesia (regional pain control) in addition to general anesthesia at the time of surgery might improve the long-term oncological outcomes of men undergoing a radical prostatectomy for adenocarcinoma of the prostate.

Using the Mayo Clinic’s surgical database and electronic medical records, Scavonetto et al. were able to identify 1,642 men who underwent a radical prostatectomy under general anesthesia at their institution between January 1991 and December 2005 together with neuraxial analgesia; they were also able to match these men 1:1 (based on age, surgical year, pathological stage, Gleason scores, and presence of lymph node disease) with men who had a radical prostatectomy under general anesthesia alone.

They were able to demonstrate the following:

  • Average (median) patient follow-up was 9 years.
  • After appropriate adjustments for comorbidities, positive surgical margins, and adjuvant hormonal and radiation therapies within 90 days post-surgery
    • General anesthesia alone was associated with
      • Increased risk for systemic cancer progression (hazard ratio [HR] = 2.81)
      • Higher overall mortality (HR = 1.32)
    • Similar findings were observed for prostate cancer-specific mortality (adjusted HR = 2.2), but these finding were not statistically significant.

The authors conclude that their study “suggests a possible beneficial effect of regional anesthetic techniques on oncological outcomes after prostate surgery for cancer.” They are also very clear that their findings need to be appropriately tested in randomized clinical trials.

The “New” Prostate Cancer InfoLink does wonder just how many men are being treated post-surgery with opioid anesthetics in the current era of robot-assisted radical prostatectomy.

Laparoscopic radical prostatectomy (with or without the use of a surgical robot) has been associated with a major reduction in the need for systemic pain relief post-surgery by comparison with the older open surgical technique. Thus accrual of patients to a clinical trial large enough to test this hypothesis, and the need to follow such patients for (probably) a minimum of at least 5 years, might present a problem all on its own. When one adds in the fact that there is likely to be a decrease in the number of men undergoing radical prostatectomy as a first-line treatment for prostate cancer over the next few years (because of wider acceptance of active surveillance and uptake of other, newer forms of treatment, possibly including high-intensity focused ultrasound), there have to be very real questions about the feasibility of a trial to test the authors’ proposed hypothesis.

2 Responses

  1. This seems like the most important takeaway:

    — General anesthesia alone was associated with increased risk for systemic cancer progression (hazard ratio [HR] = 2.81)

    Doug

  2. Yes, it does, hypothetically. But this is just an association. Without proof from some form of prospective trial, it is just an hypothesis.

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