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Regional anaesthesia to improve cancer survival‐still too good to be true?
ESRA Academy. Borgeat A. Mar 7, 2017; 170347
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Cata et al undertook another retrospective study looking at the possible effect of regional anaesthesia on cancer recurrence and survival. Seven hundred and ninety‐two women with nonmetastatic breast cancer were included in this work. The authors found that the administration of a paravertebral block did not influence either the recurrence of metastasis nor the survival compared to a control group, who received morphine‐based analgesia. This work needs some comment since it was not able to avoid the limits and weaknesses of any retrospective investigation, namely the lack of randomisation, the absence of standardisation and missing or incomplete data. Moreover, there is a great imbalance between the groups since only 25% were given a paravertebral block. This can be considered as a major flaw, which could not be corrected despite the use of a sophisticated statistical manipulation. Other problems are the lack of precise drug administration. It is not clear how much local anaesthetic had been given to each patient. The mixture given in the paravertebral space also included clonidine, dexamethasone and adrenaline. The interactions of these drugs in this context are unclear.
The authors also mentioned the application of sevoflurane as the principal anaesthetic agent, which in contrast to propofol – used in Exadaktylos’ study (1) – might explain the lack of benefit of the paravertebral block.
In this context this study joins the more recent retrospective works raising some doubts over the potential beneficial effects of regional anaesthesia. It becomes more and more evident that the administration of a few mL of local anaesthetic blocking the perineural sodium channels will not influence cancer recurrence or survival. Some other systems, with their receptors being dose and time dependent, should also be blocked in order to ‘maybe’ positively influence the outcome. Local anesthetics have been shown in basic science research to have these properties, and with regard to improving cancer recurrence, hopes are still possible.

1. Exadaktylos AK, Buggy DJ, Moriarty DC, Mascha E, Sessler DI. Can anesthetic technique for primary breast cancer surgery affect recurrence or metastasis? Anesthesiology 2006; 105: 660‐4.

BACKGROUND AND OBJECTIVES:

The impact of regional anesthesia on breast cancer recurrence is controversial. We tested the hypothesis that the use of paravertebral block (PVB) analgesia during breast cancer surgery prolongs the recurrence-free survival (RFS) and overall survival (OS) of women with breast cancer.

METHODS:

Seven hundred ninety-two women with nonmetastatic breast cancer were included in this retrospective study. Patients were divided based on the administration of PVB analgesia for mastectomy surgeries. One hundred ninety-eight (25%) were given a PVB, the remainder were treated with opioid-based analgesia. Propensity score matching was developed using several variables. Univariate and multivariate analyses were used to assess the impact of PVB analgesia on RFS and OS.

RESULTS:

The median follow-up times for RFS and OS were 5.8 and 6 years, respectively. In the propensity score matching model, a total of 396 women were included in each group of treatment (non-PVB group, n = 198 vs PVB group, n = 198). As expected, the fentanyl consumption was significantly lower in PVB (122.8 ± 77.85 μg) patients than non-PVB subjects (402.23 ± 343.8 μg). Other variables were not statistically significant. After adjusting for several important covariates, the analysis indicated that the use of PVB is not associated with a significant change in RFS [1.60 (0.81-3.16), P = 0.172] or OS [1.28 (0.55-3.01)] survival.

DISCUSSION:

This retrospective study does not support the hypothesis that the use of regional analgesia is associated with longer survival after surgery for breast cancer.

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