Recurrence of breast cancer after anaesthesia

Abstract

We congratulate Daniel Sessler and colleagues1Sessler DI Pei L Huang Y et al.Recurrence of breast cancer after regional or general anaesthesia: a randomised controlled trial.Lancet. 2019; 394: 1807-1815Summary Full Text Full Text PDF PubMed Scopus (121) Google Scholar for completing their large multicentre trial, but we have concerns regarding the methodology and results. The authors report that paravertebral block techniques varied per study site across the 13 hospitals in eight countries. Typically, five levels are blocked with long-acting local anaesthetic and supplementation with sevoflurane was permitted.1Sessler DI Pei L Huang Y et al.Recurrence of breast cancer after regional or general anaesthesia: a randomised controlled trial.Lancet. 2019; 394: 1807-1815Summary Full Text Full Text PDF PubMed Scopus (121) Google Scholar In our opinion, standardisation of the study group treated with paravertebral block as the primary anaesthetic and confirmation of block efficacy are essential to evaluate important outcomes, such as cancer recurrence and chronic pain. We believe the information about block levels included in table 1 is meaningless because details of the regional block level are limited to breast quadrants, which is not how paravertebral block levels are routinely characterised and should be replaced with detailing blocked thoracic dermatomes. In addition, despite the post-hoc analysis, sevoflurane supplementation in 176 patients (17%) of the regional group is very concerning for block failure. Furthermore, without preoperative assessment of block efficacy, the percentage of failed blocks could be much higher than 17%, especially since patients in the regional anaesthesia group also received intraoperative propofol, rocuronium, and morphine. Similar postoperative 48 h morphine equivalents consumption between groups and the complete absence of data regarding pain scores in the postanaesthesia care unit support this concern. Previous studies suggest that paravertebral blocks decrease opioid consumption and pain postoperatively,2Schnabel A Reichl SU Kranke P Pogatzki-Zahn EM Zahn PK Efficacy and safety of paravertebral blocks in breast surgery: a meta-analysis of randomized controlled trials.Br J Anaesth. 2010; 105: 842-852Summary Full Text Full Text PDF PubMed Scopus (238) Google Scholar and that the paravertebral blocks uniquely provide complete CNS deafferentation,3Richardson J Jones J Atkinson R The effect of thoracic paravertebral blockade on intercostal somatosensory evoked potentials.Anesth Analg. 1998; 87: 373-376PubMed Google Scholar minimising neuroendocrine surgical stress response4Giesecke K Hamberger B Jarnberg PO Klingstedt C Paravertebral block during cholecystectomy: effects on circulatory and hormonal responses.Br J Anaesth. 1988; 61: 652-656Summary Full Text PDF PubMed Scopus (62) Google Scholar and improving immune function.5Pérez-González O Cuéllar-Guzmán LF Soliz J Cata JP Impact of regional anesthesia on recurrence, metastasis, and immune response in breast cancer surgery: a systematic review of the literature.Reg Anesth Pain Med. 2017; 42: 751-756Crossref PubMed Scopus (37) Google Scholar These methodological issues might have affected the results of this trial. Consequently, we feel strongly that more trials comparing surgical paravertebral blocks and general anaesthesia are required to draw accurate conclusions. We declare no competing interests. Recurrence of breast cancer after anaesthesiaDaniel Sessler and colleagues1 compared regional (paravertebral blocks and propofol) with general (sevoflurane and opioid-based analgesia) anaesthesia on breast cancer recurrence in their randomised controlled trial. They concluded that regional anaesthesia did not reduce cancer recurrence after surgery for primary breast cancer compared with general anaesthesia. Full-Text PDF Recurrence of breast cancer after anaesthesiaDaniel Sessler and colleagues1 presented the findings from their multicentre, randomised trial that compared the effect of regional anaesthesia (paravertebral block and propofol) with general anaesthesia (sevoflurane) and opioids on breast cancer recurrence and postoperative pain after potentially curative surgery. Regional anaesthesia was reported to be equivalent to general anaesthesia regarding disease recurrence and postoperative pain.1 Full-Text PDF Recurrence of breast cancer after anaesthesia – Author's replyI thank Masashi Ishikawa and colleagues, Karen Nielsen and colleagues, and Dimitrios Moris and Michael Kontos for their comments on the results of the randomised controlled trial of recurrance of breast cancer after regional or general anaesthesia.1 Full-Text PDF Recurrence of breast cancer after regional or general anaesthesia: a randomised controlled trialIn our study population, regional anaesthesia-analgesia (paravertebral block and propofol) did not reduce breast cancer recurrence after potentially curative surgery compared with volatile anaesthesia (sevoflurane) and opioids. The frequency and severity of persistent incisional breast pain was unaffected by anaesthetic technique. Clinicians can use regional or general anaesthesia with respect to breast cancer recurrence and persistent incisional pain. Full-Text PDF