Cordotomy in mesothelioma-related pain: a systematic review

CASP AnalysisEmma Lowe

Did the review address a clearly focused question?

Did the review address a clearly focused question?

• Clearly set out PICO• P – Patients with mesothelioma where the

intension was to perform cordotomy• I – Cordotomy• C – Treatment for pain using other modalities• O – Effectiveness of pain relief and side effects

Did the authors look for the appropriate sort of papers?

Did the authors look for the appropriate sort of papers?

• Excluded reviews and single case reports• 9 papers included• All included papers all seem relevant• All studies were case series – lowest form of

evidence – reflects the poor quality of evidence available

Do you think the important, relevant studies were included?

Do you think the important, relevant studies were included?

• Search strategy designed for sensitivity not specificity.• Basically searched for every trial about cordotomy and then

manually reviewed (2385 to 9!)• 14 databases• Reviewed reference lists from included studies and

previous reviews• No limits on language, year of publication or publication

status• Nil specific about contacting trialists although they did get

some unpublished data (one was an author, one is a consultant in Warwick)

Did the review’s authors do enough to assess the quality of the included studies?

Did the review’s authors do enough to assess the quality of the included studies?

• All had 1 or more limitation – loss to follow up of >10%, non-consecutive, reterospective, more than 20 years old, <10 patients.

• Acknowledge that all low in the hierarchy of evidence.

• Mention that 3 of the studies were single author studies - ?less generalisable and reliable

• Table

If the results of the review have been combined, was it reasonable to do so?

If the results of the review have been combined, was it reasonable to do so?

• Attempted to combine a lot of information• No one bit of information available across all studies. • Different time scales where pain was measured• Different reporting methods. • Grouped pain into complete, partial or poor pain relief

for 6 studies. • Meta-analysis – One calculated as a random-effects

model and one as a fixed-effect model (not clear why)• Account for the heterogeneity due to 2 small studies.• No one table presents all the results (likely as so varied).

What are the overall result of the reviews?

What are the overall result of the reviews? 1

• All 9 studies demonstrated good pain relief in the majority of patients– In patients where cordotomy was intended there

was complete pain relief in 20-100% (75%)– In patients where cordotomy was performed there

was complete pain relief in 33-100% (83%)– Analgesia use appeared reduced (less specific

information)

What are the overall result of the reviews? 2

• Initial effect was the greatest. This reduced over time but never to pre-procedure levels

• Other outcomes also showed beneficial effect (increased performance status, sleep, patient satisfaction)

• Range of adverse events, most of which were transient.

• Deaths all attributed to disease progression rather than procedure.

How precise are the results?

How precise are the results?

• Intended cordotomy 95% CI 52-89%• Performed cordotomy 95% CI 72-90%• Other data unable to be assimilated and came

from small number of studies or different information.

Can the results be applied to the local population?

Can the results be applied to the local population?

• Mesothelioma patients likely to receive palliative care. • Not all patients who have cordotomy have

mesothelioma.• Data from other patients excluded ?are they planning on

a separate review to look at this.• Minimal consideration by authors to generalisability• No clear indication of when cordotomy was considered.• Minimal information about participants in the studies

(mainly men, large range of ages, most patients on multiple analgesia.

• Post procedure survival confusing (227-36,527 days, although individual patients died sooner in some studies)

Were all important outcomes considered?

Were all important outcomes considered?

• Seem to have looked at a reasonable amount. • No-one looked at function or ADLs• All seem to have looked at pain, adverse

events and 1 other things with minimal consistency.

Are the benefits worth the harms and costs?

Are the benefits worth the harms and costs?

• Not addressed by the reviewers.• No economic evaluation or even estimate of the

costs. • Presumably relatively expensive treatment with

intensive training needed for treatment of a small number of individuals.

• However, useful treatment for patients with ‘intractable’ pain.

• More research needed, although also some ideas about how to do this.

The End