Cordotomy in mesotheliomarelated pain: a systematic review
CASP Analysis
Emma 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?
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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get some unpublished data (one was an author, one is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?
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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