Ann Robinson’s research reviews—13 December 2019

Ann Robinson reviews the latest research from the top medical journals

Accelerated breast irradiation for breast cancer

Daily irradiation of the whole breast over three to five weeks after breast conserving surgery is known to reduce local recurrence of cancer with good cosmetic results. Accelerated partial breast irradiation (APBI) is given twice a day for just one week, which is clearly more convenient for patients. But is it as effective and safe? This study found that APBI was non-inferior to whole breast irradiation. Overall, the breast cancer recurrence rate in the same breast was lower than expected, which is good news for the study participants. There was less acute toxicity, but more moderate late toxicity and a worse cosmetic outcome with ABPI. Because of this, the authors say that twice daily ABPI can’t be recommended in clinical practice. Daily APBI might cause less damage and be an option, however, and it is being studied now.

Lancet doi:10.1016/S0140-6736(19)32515-2

Talc solutions

Low tech talc powder to induce a pleurodesis remains an effective way to manage malignant pleural effusions. There are two methods; introducing the talc powder (poudrage) via thoracoscopy or using talc slurry (a talc and saline sludge) via a chest drain. This study found that they work equally well, with failure rates of 22-25% at 90 days. There were no differences in other important (but not always measured) outcomes such as patient reported thoracic pain, breathlessness, and health related quality of life. The authors admit that the study may have been underpowered to detect small but potentially important differences. Longer follow-up, blinded trials (this one was open label), and the inclusion of frailer patients would provide more information, but in the meantime there seems little to choose between the two methods.

JAMA doi:10.1001/jama.2019.19997

Spinal cord compression; single versus multiple doses of radiotherapy? The jury’s out

Spinal cord or cauda equina compression due to metastatic cancer is treated with radiotherapy to relieve pain and maintain mobility. There’s no standard radiotherapy regimen, and this study showed that a single dose of radiotherapy didn’t meet criteria for non-inferiority at eight weeks compared with multifraction radiotherapy delivered over five days. Of the 686 patients in the trial, 255 died within the eight week study period, and median survival time was only three months. Overall survival rates at 12 weeks were 50% in the single fraction radiotherapy group versus 55% in the multifraction group. The clinical significance of this study is unclear: “the observed risk differences between single-fraction and multifraction radiotherapy groups in ambulatory status were small and unlikely to be of clinical importance.” NICE guidelines currently state that radiotherapy can be given as a single dose. This study doesn’t give a clear steer either way, but if I only had three months to live, I’d opt for the one-off treatment unless it was clearly inferior.

JAMA doi:10.1001/jama.2019.17913

Options for achalasia

Achalasia is a disorder that affects lower oesophageal sphincter relaxation and peristalsis, causing dysphagia, regurgitation, pain, and weight loss. Pneumatic dilation and laparoscopic Heller’s myotomy (LHM) are established treatments for idiopathic achalasia. Peroral endoscopic myotomy (POEM) is a less invasive treatment option. This study compared the two and found similar success rates of 83% of patients in the POEM group and 81.7% of patients in the LHM group at two years. Serious adverse events occurred in 2.7% of patients in the POEM group and 7.3% of patients in the LHM group, but the POEM group had more evidence of reflux. A serious limitation of this study was that, once presented with the two choices, only half of the eligible patients agreed to randomisation. Despite the increased risk of reflux, POEM offers a less invasive option for achalasia.

N Engl J Med doi:10.1056/NEJMoa1905380

Short advice versus a leaflet to aid smoking cessation

Here is fresh evidence of how hard it is to persuade smokers to quit. A low cost intervention that involved brief (1 minute) advice based on self-determination theory (which encourages individuals to take control of their own lives) was compared with handing a smoking cessation leaflet to smokers who presented to emergency departments in Hong Kong. The participants were nearly all men (87.9%), and the mean age was only 47 years old. Half of those who claimed that they had quit at six months’ follow-up hadn’t really; biochemical validation using exhaled carbon monoxide and salivary cotinine confirmed self reported abstinence in only 50.3%. Overall, 6.7% of the intervention group quit (biochemically validated at 6 months) compared with 2.8% of the smokers who were just given a leaflet. It’s not a dramatic result, but at a cost of US$0.47 per intervention, it’s worth a go. Perhaps a longer conversation would yield better results?

JAMA Intern Med doi:10.1001/jamainternmed.2019.5176

Ann Robinson is an NHS GP and health writer and broadcaster