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The Cochrane Collaboration is an international not-for-profit organization, providing up-to-date information about the effects of health care. Here are some of the new reviews available in the Cochrane Library:
Homeopathic medicines for adverse effects of cancer treatments:
Homeopathic medicines are used by many patients with cancer, usually alongside conventional treatment. Cancer treatments can cause adverse effects, and one of the reasons patients use homeopathic medicines is to help with these symptoms. This review looked at whether these medicines could help patients with problems caused by cancer treatments. Eight studies with a total of 664 participants were included in this review. Three studied adverse effects of radiotherapy, three studied adverse effects of chemotherapy and two studied menopausal symptoms associated with breast cancer treatment. Two studies with low risk of bias demonstrated benefit: one with 254 participants demonstrated benefits from calendula ointment in the prevention of radiotherapy-induced dermatitis, and another with 32 participants demonstrated benefits from Traumeel S (a complex homeopathic medicine) over placebo as a mouthwash for chemotherapy-induced stomatitis. These trials need replicating. Two other studies reported positive results, although the risk of bias was unclear, and four further studies reported negative results. The homeopathic medicines used in all eight studies did not seem to cause any serious adverse effects or interact with conventional treatment. No cancer treatments were modified or stopped because of the homeopathic interventions.
Rituximab as maintenance therapy for patients with follicular lymphoma:
Follicular lymphoma is a B-cell lymphoma characterised by an initial response to treatment that is usually followed by relapse and progression. Most patients present with advanced disease that cannot be cured. Lymphoma B-cells express CD20. Rituximab, a monoclonal anti-CD20 antibody, is expected to be active against cells that express CD20. Compared to chemotherapy alone, rituximab in combination with chemotherapy improves overall survival when used for induction therapy (treatment designed as a first step toward reducing the number of cancer cells) for patients with newly diagnosed or relapsed indolent lymphoma. Clinical trials that have shown improved event-free survival were inconsistent regarding overall (all-cause) survival. We aimed to evaluate the effects of maintenance therapy with rituximab on overall survival in patients with follicular lymphoma.
Study design: systematic review and meta-analysis of five randomised controlled trials (1056 patients).
Contribution: patients with follicular lymphoma and high tumour burden treated with rituximab maintenance therapy had better overall survival and disease control but more infections than patients who were observed without rituximab.
Implications: rituximab maintenance therapy should be added to the standard therapy of patients with relapsed or refractory (to treatment) follicular lymphoma following a successful induction treatment.
Limitations: variability in treatment regimens among trials precluded determination of the optimal rituximab maintenance regimen. One trial compared rituximab maintenance to rituximab at disease progression for patients with lower tumour burden and found both options to be comparable.
Future research should focus on: the effect of rituximab maintenance compared to rituximab at progression; defining which patients benefit the most from rituximab, according to burden of disease, prognostic score, the type of chemotherapy regimens used for induction, and the inclusion of rituximab in induction; and the optimal duration of maintenance treatment, as well as its schedule.
Both randomised controlled trials and observational trials should have longer follow up in order to assess the long-term toxicity of rituximab, and should evaluate quality of life outcomes.
Surgery versus endoscopic therapies for early oesophageal cancer in Barrett's oesophagus:
This Cochrane review has indicated that there are no randomised controlled trials to compare management options in this vital area, therefore trials should be undertaken as a matter of urgency. Current use of endotherapies in the care of patients with early cancer or high grade dysplasia of Barrett's oesophagus should be at the recommendation of the multi-disciplinary team involved in individual care. Properly conducted randomised controlled trials comparing surgery with endotherapies should be conducted before any conclusions can be drawn.
Second-line chemotherapy may increase survival of patients with advanced or metastatic colorectal cancer that have failed a first chemotherapy treatment:
Patients with metastatic or advanced colorectal cancer are often treated with chemotherapy. If the disease doesn't improve with a specific chemotherapy regimen, a different chemotherapy regimen may be tried, called second-line treatment, with the aim to increase survival and improve quality of life. This review has identified a single trial comparing second-line chemotherapy with supportive care. Based on its results, chemotherapy may increase overall survival in 4 to 8 weeks with respect to supportive care. Although the review has identified six trials comparing different second-line chemotherapy regimens, no conclusive results were reached and it's not clear which is the optimal chemotherapy regimen. The review has failed to identify any evidence on third and subsequent lines of therapy, which thus are not currently supported by sound evidence.
Single agent versus combination chemotherapy for metastatic breast cancer:
Metastatic breast cancer is cancer that has advanced and spread beyond the breast and regional lymph nodes. Although many women will live with advanced disease for many years, treatment is aimed at the alleviation of symptoms rather than cure. The first choice of treatment for advanced disease is dependent on hormone status (whether the tumour is stimulated to grow by oestrogen and progesterone) or whether the tumour overexpresses human epidermal growth factor receptor-2 (HER-2) and can be treated with trastuzumab (herceptin). Most women with advanced disease will however receive chemotherapy (anti-cancer agents) either as their first treatment, because their disease has become resistant to some treatments, or in combination with other types of treatments. Chemotherapy drugs can be given alone (single agent) or two or more drugs can be given together (combination chemotherapy). The aim of this review was to compare whether using a more intensive regimen (more than one drug) was better than the single agent treatment for women with advanced disease. We identified 43 eligible trials (48 comparisons- as some trials tested more than one comparison). These trials included 9742 women, 55% of whom were receiving their first treatment with chemotherapy for metastatic disease. The review found a benefit for the combination chemotherapy for survival (all trials). This was also the case when trials of first-line treatment only were analysed, and whether the single agent was also included in the combination or not. Combination treatments were also associated with significantly better time to progression (time after treatment until the disease progressed) and response (whether the tumour gets smaller as a result of the treatment). Women receiving combination treatment however experienced more adverse effects of treatment including a decrease in their white cell count, increased hair loss and nausea and vomiting. For women making a decision about treatment, it should be noted that this review was not able to address the issue of whether combination regimens are more effective than sequential treatment with different single agents. Some individual trials raised the possibility that giving a multiagent regimen sequentially with immediate cross-over from one agent to the next on progression may result in survival times similar to that seen when all the agents are given together
An important consideration for women with advanced disease is the balance between the benefit of treatment and the harms or adverse effects that these treatments may have. Unfortunately only 11 trials in this review reported information relating to quality of life. In general, survival gains with combination therapy came at the cost of a significant increase in toxicity and impact on other psychological and social factors which are known to contribute to a sense of quality of life for this group of women. There were insufficient data in this review to comment on the overall impact of the two treatment options on net clinical benefit from the women's perspective. Women with advanced disease will therefore need to seek the information to allow them to make decisions about the potential benefits of additional treatments (small survival gains) in progressing metastatic disease and the impact this can have on their quality of life.
The Research Medical Library has an evidence-based health care portal with links to the Cochrane Library and other recommended databases. For questions about evidence-based resources or instruction contact Clara Fowler at firstname.lastname@example.org.
For up-to-the-minute information about the Research Medical Library, follow us on Twitter: http://twitter.com/MDAndersonLib
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