ABSTRACT
Background: Loco-regional renal cell carcinoma [RCC] accounts for 15 to 20 percent of patients with RCC, with a risk of post-surgical relapse of 40 percent [1,2]. Following the adoption of tyrosine kinase inhibitors [TKIs] as the first-line treatment of metastatic RCC, multiple studies evaluated Sunitinib [3,4] and Pazopanib [5] in the adjuvant setting of high-risk resected RCC. However, these studies have yielded inconclusive results, and there are currently no meta-analyses combining the results of all trials evaluating TKIs in the adjuvant setting of high-risk RCC. The aim was to perform a meta-analysis to evaluate and compare the possible benefit of Sunitinib and Pazopanib on diseasefree survival [DFS] in the adjuvant setting of high-risk RCC
Methods: This meta-analysis included all the phase 3 randomized controlled trials [ASSURE 3, S-TRAC 4 and PROTECT 5] evaluating Sunitinib and Pazopanib in the adjuvant setting of high-risk RCC. A random-effects model was preferentially used to pool the data using the inverse variance method and a subgroup analysis including Sunitinib and Pazopanib subgroups was used in order to account for heterogeneity and allow comparison of the two subgroups. Two variations of the same analysis were undertaken as sensitivity analyses : first with a fixed-effects model, second while excluding the results of the ASSURE study. The primary outcome was the comparison of disease-free survival [DFS] between TKIs and placebo. Hazard ratios were reported along with their 95 percent confidence intervals [95 percentCI]
Results: A total of 3447 patients from the three trials were included in the analysis. There was a tendency for a significant overall effect of both TKIs on DFS; however, this tendency only reached the threshold for statistical significance in the fixed-effects model [HR = 0.91; 95 percentCI = 0.83-0.99; p = 0.03] but not in the random-effects model [HR = 0.85; 95 percentCI = 0.72-1.01; p = 0.06, Figure 1]. Significant between-study overall heterogeneity was observed [p = 0.07; I2 = 58 percent] and the subgroup analysis showed that this was largely due to the heterogeneity within the Sunitinib subgroup [p = 0.05; I2 = 73 percent, Figure 1]. Moreover, a sensitivity analysis excluding the ASSURE study led to results which were markedly more homogeneous [p = 0.48; I2 = 0 percent]. While the test for overall effect was found to be significant in the Pazopanib subgroup [HR = 0.80; 95 percentCI = 0.65-0.98; p = 0.03] but not in the Sunitinib subgroup [HR = 0.90; 95 percentCI = 0.67-1.19; p = 0.45], there was no significant difference between the subgroup effects [p = 0.51; I2 =0 percent; Figure 1]
Conclusion: Our analysis showed that Pazopanib and Sunitinib could still have a potential role in the armamentarium of adjuvant treatment in high-risk RCC. However, it failed to demonstrate a significant difference between these agents in this setting
ABSTRACT
Aim: The administration of total parenteral nutrition [TPN] in terminally ill cancer patients is aggressive with a relatively high risk of complications. In this paper, we investigated the use of TPN in Lebanese cancer patients at end of life. To our knowledge, this is the first study describing TPN administration to Middle Eastern patients with advanced cancer
Methods: We conducted this observational study at Hotel-Dieu de France University Hospital, Lebanon. Eligible cases included all cancer patients that died at our institution between the 1st of January and the 31st of December 2014. The patients and tumors characteristics as well as the management plan were retrieved from the hospital records
Results: Our study enrolled 129 cancer patients at end of life among which 39 percent had received TPN: 28 percent during the last 6 weeks and 34 percent during the last 3 months. The mean duration of TPN administration was 33 days [range: 1 to 211]. The mean duration between the end of TPN administration and death was 37 days [range: 0 to 315]. TPN administration correlated negatively to hyperlipidemia [OR = 0.33; 95 percent CI [0.12 - 0.87]] and to the presence of three cardiovascular risk factors [OR = 0.28; 95 percent CI [0.10 - 0.80]]. On the other hand, it correlated positively to gastrointestinal tumors [OR = 3.9; 95 percent CI [1.3 - 11.7]] and to imaging studies during the last month of life [OR = 3.4; 95 percent CI [1.3 - 9.0]]. In the multivariate analysis, only hyperlipidemia was found to be a significant determinant of the TPN administration [p = 0.010; ORa= 0.29 [0.11 - 0.74]
Conclusion: The prevalent use of TPN at end of life underlines a difficulty in adopting a palliative care approach in our population. This is truly applicable in Middle Eastern populations that seem to refuse a patient-centered supportive care approach