Clinical trial NCT02660411: Impact of Anesthesia Maintenance Methods on Long-term Survival
Official title: Impact of Inhalational Versus Intravenous Anesthesia Maintenance Methods on Long-term Survival in Elderly Patients After Cancer Surgery: a Randomized Controlled Trial
Study type: INTERVENTIONAL
Overall status: COMPLETED
Phase: NA
Conditions: Aged
Neoplasms
Surgical Procedure, Operative
Anesthesia, Inhalation
Anesthesia, Intravenous
Survival
Keywords: Sevoflurane
Propofol
Aged
Neoplasm
Surgical Procedure, Operative
Long-term survival
Lead sponsor: Peking University First Hospital
Sponsor class: OTHER
Collaborators: name: Hebei Medical University Fourth Hospital
name: The People's Hospital of Ningxia
name: Beijing Shijitan Hospital, Capital Medical University
name: Guizhou Provincial People's Hospital
name: Affiliated Hospital of Qinghai University
name: The Third Xiangya Hospital of Central South University
name: Cancer Hospital of Guangxi Medical University
name: Shanxi Provincial People's Hospital
name: Zhongda Hospital
name: The First Affiliated Hospital of Zhengzhou University
name: Tang-Du Hospital
name: Tianjin Nankai Hospital
name: Shenzhen Second People's Hospital
First posted: 2016-01-21
Enrollment: 1228
Sex: ALL
Minimum age (years): 65
Maximum age (years): 90
Standard ages: OLDER_ADULT
Accepts healthy volunteers: no
Allocation: RANDOMIZED
Intervention model: PARALLEL
Primary purpose: PREVENTION

Brief summary: Surgery is one of the major treatment methods for patients with malignant tumor. And, alone with the ageing process, more and more elderly patients undergo surgery for malignant tumor. Evidence emerges that choice of anesthetics, i.e., either inhalational or intravenous anesthetics, may influence the outcome of elderly patients undergoing cancer surgery. From the point of view of immune function after surgery and invasiveness of malignant tumor cells, propofol intravenous anesthesia may be superior to inhalational anesthesia. However, the clinical significance of these effects remains unclear. Retrospective studies indicated that use of propofol intravenous anesthesia was associated higher long-term survival rate. Prospective studies exploring the effect of anesthetic choice on long-term survival in cancer surgery patients are urgently needed.

Detailed description: It is estimated that 234.2 million major surgical procedures are undertaken every year worldwide. Surgery is one of the major treatment methods for patients with malignant tumor. And, alone with the ageing process, more and more elderly patients undergo surgery for malignant tumor. However, evidence emerges that choice of anesthetics, i.e., either inhalational or intravenous anesthetics, may influence the outcome of elderly patients undergoing cancer surgery.

A. Effects of anesthetics on immune function after surgery

The choice of general anesthetics might influence human's immune function after surgery. An international multicenter team (NCT00418457) investigated the effects of propofol-paravertebral anesthesia vs sevoflurane-opioid anesthesia on the immune function in patients after breast cancer surgery. In a small sample size (n = 32) randomized controlled trail published in 2010, postoperative serum concentrations of interleukin (IL)-1 (protumorigenic cytokine) and matrix metalloproteinases (MMP)-3/9 (associated with cancer cell invasion and metastasis) were significantly lower (P = 0.003 and 0.011, respectively), whereas that of IL-10 (antitumorigenic cytokines) was significantly higher in the propofol group than in the sevoflurane group (P = 0.001). In another small sample size (n = 10) randomized controlled trail published in 2014, serum obtained from patients who received propofol anesthesia led to greater human donor natural killer (NK) cell cytotoxicity in vitro when compared with serum from those who received sevoflurane anesthesia. In a recent small sample size (n = 28) randomized controlled trial, the levels of NK and T helper cell infiltration in breast cancer tissue were significantly higher in patients receiving propofol anesthesia than those receiving sevoflurane anesthesia (P = 0.015 and 0.03, respectively).

Similar findings were reported in patients with other malignant tumors. In a small randomized controlled trial, 30 patients with non-small-cell lung cancer randomly received either propofol or isoflurane anesthesia. The results showed that cluster of differentiation (CD)4+CD28+ percentage (P \< 0.0001) and the ratio of interferon-gamma:interleukin-4 (P = 0.001) all increased significantly with propofol but no change with isoflurane anesthesia; indicating that propofol promotes activation and differentiation of peripheral T-helper cells. In another randomized controlled trial, 60 patients undergoing surgery for tongue cancer surgery randomly received total propofol, mixed (propofol induction and sevoflurane maintenance) anesthesia or total sevoflurane anesthesia. The results showed that the percentages of CD3+, CD3+CD4+, and NK cells and the ratio of CD4+/CD8+ were significantly decreased in the two sevoflurane groups, but not in the total propofol group; suggesting that propofol has less effects on cellular immune response than sevoflurane. There are also studies that reported neutral results.

The above studies suggest that, when compared with inhalational anesthesia, propofol intravenous anesthesia may have favorable effects on the immune function in patients after cancer surgery. However, care must be taken when explaining these results: (1) the sample sizes of the available studies were small; (2) the relationship between postoperative immune function changes and long-term outcomes remains unclear.

B. Effects of anesthetics on invasiveness of malignant tumor

The effects of anesthetics on invasiveness of tumor cells were mainly tested in the experimental studies, i.e., tumor cells were incubated with anesthetics in the in vitro environment. In this aspect, propofol shows somewhat favorable effects. The results of Miao et al. showed that propofol stimulation decreased the expression of MMP-2 and -9 and subsequently decreased the invasive activity of human colon cancer cells, possibly via extracellular signal-regulated kinase 1/2 (ERK1/2) down-regulation mediated through the gamma-aminobutyric acid (GABA)-A receptor. The study of Wang et al. reported that propofol inhibited invasion and metastasis, and enhanced paclitaxel-induced apoptosis of ovarian cancer cells, possibly by suppressing the Slug expression. Ecimovic et al. also reported that propofol reduced migration in both estrogen receptor-positive and -negative breast cancer cells, possibly by suppressing the Neuroepithelial Cell Transforming Gene 1 (NET1) expression.

The reported effects of various inhalational anesthetics are conflicting. Huang et al. compared the effects of propofol and isoflurane on prostate cancer cells. The results showed that propofol, at clinical relevant concentration, inhibited the activation of hypoxia-inducible factor (HIF)-1 alpha, and partially reduced cancer cell malignant activities; whereas isoflurane raised HIF-1 alpha expression, and increased the probability of proliferation and migration. The study of Benaonana et al. reported similar results, i.e., isoflurane up-regulated the expression of HIFs, and increased the growth and malignant potential of renal cancer cells. On the other hand, sevoflurane and desflurane show opposite effects. Multiple studies found that sevoflurane inhibited the proliferation and migration, and induced apoptosis of lung cancer cells. Müller-Edenborn et al. also reported that volatile anesthetics (sevoflurane and desflurane) reduced invasion of colorectal cancer cells through down-regulation of matrix metalloproteinase-9.

So far, the clinical significance of anesthetics on the invasiveness of malignant tumors is still lacking.

C. Effect of anesthetics on long-term outcome after cancer surgery

Studies in this aspect are very limited. In the study of Enlund et al., 2838 patients who underwent breast cancer or colorectal cancer surgery were retrospectively analyzed, among them 1935 received sevoflurane anesthesia and 903 propofol anesthesia. The 1-year and 5-year survival rates were higher in propofol-anesthetized patients than in sevoflurane-anesthetized ones (differences in overall survival rate were 4.7%, P = 0.004 and 5.6%, P \< 0.001, respectively). However, the differences were not statistically significant after adjusting for confounding factors. In a recent study, Wigmore et al. retrospectively investigated 11,395 patients after cancer surgery. After exclusions and propensity matching, 2,607 patients remained in each of the inhalational anesthesia group or total intravenous anesthesia group. The results showed that, after a median follow-up duration of 2.66 years (95% confidence interval \[CI\] 2.62-2.69), volatile inhalational anesthesia was associated with a higher risk for death after both univariate (HR 1.59, 95% CI 1.30-1.95) and multivariable analysis (HR 1.46, 95% CI 1.29-1.66).

However, in this aspect, long-term follow-up results of randomized controlled trials are still lacking. Prospective studies exploring the effect of anesthetic choice on long-term survival in cancer surgery patients are urgently needed.

Eligibility criteria: Inclusion Criteria:

* Participants will be included if they meet all the following criteria:

  1. Age ≥ 65 years and \< 90 years;
  2. Primary malignant tumor;
  3. Do not receive radiation therapy or chemotherapy before surgery;
  4. Scheduled to undergo surgery for the treatment of tumors, with an expected duration of 2 hours or more, under general anesthesia;
  5. Agree to participate, and give signed written informed consent.

Exclusion Criteria:

* Patients will be excluded if they meet any of the following criteria:

  1. Preoperative history of schizophrenia, epilepsy, parkinsonism or myasthenia gravis;
  2. Inability to communicate in the preoperative period (coma, profound dementia, language barrier, or end-stage disease);
  3. Critical illness (preoperative American Society of Anesthesiologists physical status classification ≥ IV), severe hepatic dysfunction (Child-Pugh class C), or severe renal dysfunction (undergoing dialysis before surgery);
  4. Neurosurgery;
  5. Other reasons that are considered unsuitable for participation by the responsible surgeons or investigators (reasons must be recorded in the case report form).

Primary outcomes:
measure: Over survival after surgery.
timeFrame: Up to 5 years after surgery.
Secondary outcomes:
measure: Recurrence-free survival after surgery
timeFrame: Up to 5 years after surgery
measure: Event-free survival after surgery
timeFrame: Up to 5 years after surgery
Other outcomes:
measure: Quality of life in 3-year survivors after surgery.
timeFrame: Assessed at the end of the 3rd year after surgery.
measure: Cognitive function in 3-year survivors after surgery.
timeFrame: Assessed at the end of the 3rd year after surgery.
Locations:
city: Beijing
country: China
facility: Department of Anesthesiology and Critical Care Medicine, Peking University First Hospital
state: Beijing
city: Beijing
country: China
facility: Beijing Shijitan Hospital
state: Beijing
city: Beijing
country: China
facility: Peking University Cancer Hospital
state: Beijing
city: Beijing
country: China
facility: University School and Hospital of Stomatology
state: Beijing
city: Nanning
country: China
facility: Cancer Hospital of Guangxi Medical University
state: Guangxi
city: Shenzhen
country: China
facility: Shenzhen Second People's Hospital
state: Guangzhou
city: Guiyang
country: China
facility: Guizhou Provincial People's Hospital
state: Guizhou
city: Shijiazhuang
country: China
facility: Hebei Medical University Forth Hospital
state: Hebei
city: Zhenzhou
country: China
facility: The First Affiliated Hospital of Zhengzhou University
state: Henan
city: Changsha
country: China
facility: The Third Xiangya Hospital of Central South University
state: Hunan
city: Nanjing
country: China
facility: Zhongda Hospital
state: Jiangsu
city: Yinchuan
country: China
facility: Ningxia People's Hospital
state: Ningxia
city: Xining
country: China
facility: Affiliated Hospital of Qinghai University
state: Qinghai
city: Xi'an
country: China
facility: Tang-Du Hospital
state: Shaanxi
city: Taiyuan
country: China
facility: Shaanxi Provincial People's Hospital
state: Shanxi
city: Taiyuan
country: China
facility: Shanxi Province Cancer Hospital
state: Shanxi
city: Tianjin
country: China
facility: Tianjin Nankai Hospital
Study officials:
affiliation: Peking University First Hospital
name: Dong-Xin Wang, MD, PhD
role: PRINCIPAL_INVESTIGATOR
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