A Comparison of the Effects of Epidural Analgesia Versus Traditional Pain Management on Outcomes After Gastric Cancer Resection

Abstract

Background and Objectives Epidural analgesia may increase survival after cancer surgery by reducing recurrence. This population-based study compared survival and treated recurrence after gastric cancer resection between patients receiving epidurals and those who did not. Methods We used the linked federal Surveillance, Epidemiology, and End Results (SEER) Program/Medicare database to identify patients aged ≥66 with nonmetastatic gastric carcinoma diagnosed 1996–2005 who underwent resection. Exclusions included diagnosis at autopsy, no Medicare Part B, familial cancer syndrome, emergency surgery, and laparoscopic procedures. Epidurals were identified by CPT codes. Treated recurrence was defined as chemotherapy ≥ 16 months and/or radiation ≥ 12 months after surgery. Recurrence was compared by conditional logistic regression. Survival was compared via marginal Cox proportional hazards regression. Results We identified 2745 patients, 766 of whom had epidural codes. Patients receiving epidurals were more likely to have regional disease, be white, and live in areas with relatively high socioeconomic status. Overall treated recurrence was 25.6% (27.5% epidural and 24.9% non-epidural). In the adjusted logistic regression, there was no difference in recurrence (odds ratio [OR] 1.40, 95% CI 0.96 to 2.05). Median survival did not differ: 28.1 months (95% CI 24.8 to 32.3) in the epidural versus 27.4 months (95% CI 24.8 to 30.0) in the non-epidural groups. The marginal Cox models showed no association between epidural use and mortality (adjusted HR 0.93, 95% CI 0.84 to 1.03). Conclusions There was no difference between groups regarding treated recurrence or survival. Whether this is true or simply a result of insufficient power is unclear. Prospective studies are needed to provide stronger evidence.

Is there a measurable association of epidural use at cystectomy and postoperative outcomes? A population-based study

“…This observation is consistent with a recent, large, population-based study in gastric cancer using the Surveillance, Epidemiology, and End Results (SEER) Program/ Medicare database. 19 Cummings et al showed no association between epidural use and cancer recurrence or survival in 2745 patients undergoing resection of gastric cancer. 19 Furthermore, Sun and colleagues 20 recently published a meta-analysis of 18 studies evaluating the impact of epidural anesthesia on cancer outcomes.…”

“…19 Cummings et al showed no association between epidural use and cancer recurrence or survival in 2745 patients undergoing resection of gastric cancer. 19 Furthermore, Sun and colleagues 20 recently published a meta-analysis of 18 studies evaluating the impact of epidural anesthesia on cancer outcomes. Although no bladder cancer studies were included in the meta-analysis, they found that although epidurals were associated with improved OS (HR 0.84, 95% CI 0.75−0.94), it was not associated with reduced cancer recurrence (HR 0.91, 95% CI 0.70−1.18).…”

“…Subsequent literature has been less promising and several recent studies have called into question the initial optimism regarding improved cancer outcomes. 19,20 Weingarten et al 33 recently published on their series of 129 patients undergoing RC with combined general anesthetic (GA) and TEA and compared to age-matched controls undergoing oncologic surgery with only GA. In this analysis, they found no association between TEA and cancer recurrence, OS, or CSS.…”

“…Despite these encouraging early findings and a plethora of basic science evidence to support the biologic plausibility, [16][17][18] more recent analyses have been less encouraging. 19,20 This phenomenon has not been specifically investigated in the RC population.…”

Do Amide Local Anesthetics Play a Therapeutic Role in the Perioperative Management of Cancer Patients?

“…87 The study revealed recurrence rates of 27.5% and 24.0% in the epidural and the control groups, respectively. In an adjusted logistic regression analysis, the incidence of recurrence was comparable in the 2 groups (odds ratio, 1.4; 95% CI, 0.96-2.05).…”