肺癌的循证医学

这一期的中国肺癌杂志 ,是以循证医学为主题。无可否认 ,2 0世纪 90年代初露锋芒的循证医学尤其是循证肿瘤学 ,在 2 1世纪初越发显现其魅力与成熟。就肺癌临床研究领域来说 ,大量设计严谨的临床随机对照研究结果的出现和遵循循证医学基本原则建立的临床指引 ,正在越来越多、越来越快地改变我们对肺癌的诊断治疗策略和临床实践 ,结果是医生越发变得理性 ,肺癌患者越发得到更好的医疗照顾。以今年 5月份举行的第 39届美国临床肿瘤学年会 (the 39thAnnualMeetingofAmericanSocietyofClinicalOncology ,39thASCO)和 8月份举行的第 10届世界…     

循证医学对肿瘤临床实践的影响

循证医学正在越来越深刻地影响着肿瘤学的临床实践,临床随机对照研究和在这一基础上建立起来的系统分析,把一些理论上认为应该有效或经验认为有效的治疗方法。证实在实际上是无效或害大于利,而另一些被认为似乎无效的治疗方法却被证实利大于害,应该推广,本文着重探讨了疗效判断中终点指标和中间指标的不同,探讨了系统评估对肿瘤临床实践的影响。     

关于举办第一届全国“循证放射肿瘤学”学习班的通知

“循证放射肿瘤学”(Ｅｖｉｄｅｎｃｅ ｂａｓｅｄＭｅｄｉｃｉｎｅｆｏｒＲＡＤＩＡＴＩＯＮＯＮＣＯＬＯＧＹ)是近年兴起的一个新课题 ,其目的是强调在临床实践中要根据现有的科学依据为基础结合个人经验来治疗病人 ,使放射治疗更具科学性 ,对提高放射治疗的质量和疗效 ,促进放射肿瘤学的发展有重要的意义。在国际上已引起广泛的关注。国内学者对此尚缺乏了解。　　中华医学会放射肿瘤学会定于 2 0 0 0年 9月 4日～ 7日在北京举办第一届全国“循证放射肿瘤学”的学习班 ,邀请国际著名学者ＪＷＬｅｅｒ教授 ,Ｌａｚａｒｕｓ教授 ,Ｊａｋｕ…     

开拓临床肿瘤实践前沿创建腹膜肿瘤学科

腹膜种植转移是恶性肿瘤三大转移途径之一,也是临床肿瘤学长期认识不足、诊治技术水平落后的“老、大、难”问题。近30年,腹膜种植转移外科整合诊治技术体系的建立、完善和推广,引领了肿瘤腹膜转移基础、转化和临床研究热潮,推动形成了腹膜肿瘤学学科雏形,填补了临床肿瘤学的空白。基于对腹膜转移肿瘤生物学规律、特点和机制的深入认识,腹膜肿瘤临床诊断学、治疗学核心技术体系初步建成并逐渐完善,诞生了高级别循证医学证据导向的“十大里程碑”事件。2012年,《中国肿瘤临床》首推“腹膜转移癌专栏”,引领国内肿瘤学界着力研究腹膜癌诊治策略。8年来,在中国抗癌协会的大力支持下,我国腹膜肿瘤学专家协同努力,逐步完善了中国特色的腹膜癌综合诊疗技术体系,出版了国内首部腹膜癌专著,制定2项腹膜癌诊治专家共识,在学科理论形成、研究平台建设、临床实践指南等方面,全面引领了国内腹膜肿瘤学学科发展。今年再度推出“腹膜转移癌研究”专栏,系统介绍我国腹膜癌领域的最新成果,促进临床肿瘤学的发展,推动腹膜肿瘤学学科建设。     

降低乳腺癌患病风险:解读2010年NCCN《Breast Cancer Risk Reduction》

<正>2010年NCCN肿瘤学临床实践指南中《降低乳腺癌患病风险》(下面简称《指南》)已经公布。与往年相比,有些推荐内容有所更新,并且专家共识更加具体和重视循证医学的证据。     

老年食管癌的循证医学治疗

目的:探讨对老年食管癌开展循证医学治疗的意义.方法:采用循证医学的原理和方法对本院168例老年食管癌患者进行临床循证治疗.结果:168例老年食管癌患者经过3年循证治疗,取得了良好的临床效果和社会效益.同时,医务人员从中进一步掌握了老年食管癌的治疗现状和存在的问题,全面了解食管癌治疗的各种手段.结论:循证医学可提高疗效、规范临床实践、降低医疗事故发生.     

开拓临床肿瘤实践前沿创建腹膜肿瘤学科

腹膜种植转移是恶性肿瘤三大转移途径之一，也是临床肿瘤学长期认识不足、诊治技术水平落后的"老、大、难"问题。近30年，腹膜种植转移外科整合诊治技术体系的建立、完善和推广，引领了肿瘤腹膜转移基础、转化和临床研究热潮，推动形成了腹膜肿瘤学学科雏形，填补了临床肿瘤学的空白。基于对腹膜转移肿瘤生物学规律、特点和机制的深入认识，腹膜肿瘤临床诊断学、治疗学核心技术体系初步建成并逐渐完善，诞生了高级别循证医学证据导向的"十大里程碑"事件。2012年，《中国肿瘤临床》首推"腹膜转移癌专栏"，引领国内肿瘤学界着力研究腹膜癌诊治策略。8年来，在中国抗癌协会的大力支持下，我国腹膜肿瘤学专家协同努力，逐步完善了中国特色的腹膜癌综合诊疗技术体系，出版了国内首部腹膜癌专著，制定2项腹膜癌诊治专家共识，在学科理论形成、研究平台建设、临床实践指南等方面，全面引领了国内腹膜肿瘤学学科发展。今年再度推出"腹膜转移癌研究"专栏，系统介绍我国腹膜癌领域的最新成果，促进临床肿瘤学的发展，推动腹膜肿瘤学学科建设。      

循证的中医肿瘤学研究展望

循证医学要求临床工作应以各种临床试验研究结果为依据，而各种临床试验研究应具有较好的可重复性，并具备较高的研究质量，循证医学与中医学的关系渊远流长，中医肿瘤学的发展也面临着循证医学带来的机遇和挑战。     

乳腺癌患者性问题管理的证据总结

目的 以循证方法总结乳腺癌患者性问题管理的最佳证据,为临床实践提供参考。方法 计算机检索国际指南协作网、美国国立指南库、美国国立综合癌症网络、Cochrane Library、PubMed、中国知网学术文献总库等网站及数据库,收集乳腺癌患者性问题管理的临床实践指南、专家共识和系统评价,检索时限为2011年1月1日至2021年5月23日。由2名研究者进行文献质量评价,提取证据并分类总结。结果 共纳入15篇文献,其中临床实践指南1篇,专家共识6篇,系统评价/Meta分析8篇。经提炼,总结最佳证据21条,包括患者的评估、教育/培训、治疗和康复锻炼4个方面。结论 医护人员应适当开展乳腺癌患者性问题评估、性健康知识培训,并主动对患者及其伴侣进行性健康教育及选择合适的干预方式,以改善乳腺癌患者性健康问题。     

非肿块强化乳腺癌锥光束乳腺CT特征与HER2表达的相关性研究

目的 以循证方法总结乳腺癌患者性问题管理的最佳证据,为临床实践提供参考。方法 计算机检索国际指南协作网、美国国立指南库、美国国立综合癌症网络、Cochrane Library、PubMed、中国知网学术文献总库等网站及数据库,收集乳腺癌患者性问题管理的临床实践指南、专家共识和系统评价,检索时限为2011年1月1日至2021年5月23日。由2名研究者进行文献质量评价,提取证据并分类总结。结果 共纳入15篇文献,其中临床实践指南1篇,专家共识6篇,系统评价/Meta分析8篇。经提炼,总结最佳证据21条,包括患者的评估、教育/培训、治疗和康复锻炼4个方面。结论 医护人员应适当开展乳腺癌患者性问题评估、性健康知识培训,并主动对患者及其伴侣进行性健康教育及选择合适的干预方式,以改善乳腺癌患者性健康问题。     

Evidence-based medicine: its effect on treatment recommendations as illustrated by the changing role of postmastectomy irradiation to treat breast cancer

PURPOSE: To illustrate the effect that the quality of evidence has on clinical practice, we examined how the role of radiotherapy in treating breast cancer has changed over the years as the quality of evidence evolved from anecdotal evidence based on expert opinion to randomized clinical trials and meta-analyses. METHODS: We searched the medical literature for key randomized studies and meta-analyses that have influenced the clinical use of postmastectomy irradiation since the first randomized trials in breast cancer in the 1950s. We discuss how clinical practice changed based on the outcomes of these trials, and then discuss the quality of those trials based on the criteria currently used to assess evidence from randomized trials (CONSORT) and meta-analysis (QUORUM). RESULTS: Evidence published from the early trials and meta-analyses on the role of postmastectomy irradiation had a strong effect on clinical practice. Examination of these studies, however, continues to show significant flaws in trial design that, by today's evidence-based standards, would not meet standards of quality. CONCLUSION: The quality of evidence has a strong effect on shaping clinical practice and needs to be continually assessed. Current guidelines developed to critique both individual randomized trials and meta-analyses are helping to establish high standards for trial design and interpretation. Evidence from older trials that were not guided by well-developed guidelines need to be reviewed, particularly when results from those trials are continually updated and used to generate evidence on which to base current clinical practice.     

Traitements systémiques de première et de deuxième lignes des patients atteints d’un mélanome cutané métastatique (hors métastase cérébrale) : Recommandations nationales françaises

Introduction

the emergence of new molecules for the treatment of metastatic cutaneous melanoma with a significant benefit on the survival brings new therapeutic perspectives. Nevertheless, their respective use and place in the therapeutic strategy are still debated by healthcare professionals. Objective: the French National Cancer Institute leads a national clinical practice guidelines project since 2008. It realized a review of these modalities of treatment and established recommendations.

Methods

the clinical practice guidelines development process is based on systematic literature review and critical appraisal by experts. The recommendations are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines are reviewed by independent practitioners in cancer care delivery.

Results

this article presents recommendations for first-line and second-line systemic treatment of metastatic cutaneous melanoma (without brain metastatis).     

Traitements locorégionaux des sites métastatiques chez des patients atteints d’un mélanome pauci-métastatique (hors métastase cérébrale) : recommandations nationales françaises

Introductionthe last years are marked by the emergence of new molecules for the treatment of metastatic cutaneous melanoma with a significant benefit on the survival. Besides, some techniques are in development for the loco-regional treatment of the metastatic sites, bringing new therapeutic perspectives. However, their respective use and place in the therapeutic strategy are debated by healthcare professionals.Objectivethe French National Cancer Institute leads a national clinical practice guidelines project since 2008. It realized a review of these modalities of treatment and developed recommendations.Methodsthe clinical practice guidelines development process is based on systematic literature review and critical appraisal by a multidisciplinary expert workgroup. The recommendations are thus based on the best available evidence and expert agreement. Prior to publication, the guidelines are reviewed by independent practitioners in cancer care delivery.Resultsthis article presents recommendations for loco-regional treatments of the pulmonary, bone, cutaneous, hepatic and digestive metastatic sites for patients with pauci-metastatic cutaneous melanoma.     

Evidence-Based Decision Making as a Tool for Continuous Professional Development in the Medical Radiation Technologies

All components of contemporary health care practice must be supported by the best available evidence in order to maximize the potential for successful patient care. As in other disciplines, researched-based evidence is a major contributor to the development of contemporary clinical practice and decision making in the medical radiation technologies.However, in recent years a rapid proliferation of clinical studies and journal publications combined with a growing complexity of diagnostic imaging methods has made it difficult for practicing medical radiation technologists (MRT's) to remain current with the relevant clinical research. Because we rely on this clinical research evidence to determine the efficacy and applicability of new diagnostic tests and treatments, it is essential that we possess the skills for the effective procurement and interpretation of the scientific literature. For MRT's, barriers to this task may include lack of training in: defining good clinical questions, the optimal use the bibliographic databases and search engines used in accessing scientific research literature, and the appraisal and integration of acquired research evidence.Evidence-based decision making (EBDM) is a systematic process that enables the “conscientious, explicit, and judicious use of the current best evidence in making health care decisions.” 1 The development of this approach is derived in large part by the need to manage information overload. Such information is essential to the management of skyrocketing health care costs, ensuring the delivery of best diagnosis and treatment. When combined with clinical skills and judgments, patient values and expectations, the EBDM approach serves to maximize the potential for achieving successful patient care outcomes. Specifically, the implementation of EBDM has been shown to: close the gap between knowledge and practice, decrease variability in practice, and increase the use of best research evidence in practice thereby improving the level of clinical care provided by health care professionals. In this directed study article, we define the EBDM process as it pertains to medical radiation technologies.     

Leptomeningeal carcinomatosis in non-small cell lung cancer patients: A continuing challenge in the personalized treatment era

Leptomeningeal metastasis is a fatal manifestation seen in advanced cancer patients. Its incidence is increasing, reaching 3.8% in molecularly unselected non-small cell lung cancer patients and up to 5% and 9% in ALK-rearranged and EGFR-mutant lung cancer patients, respectively. The prognosis remains poor despite systemic treatment, intrathecal chemotherapy, radiation therapy and personalized treatments in molecularly selected patients. However, new therapies with improved cerebral-spinal fluid penetration have been developed for subgroups of molecular selected patients indicating they could be promising therapeutic options for managing leptomeningeal disease. Systemic chemotherapy, which may be combined with intrathecal chemotherapy, remains standard treatment for lung cancer patients with leptomeningeal disease and a good-risk profile. We summarize evidence reported in the literature for managing this complication in lung cancer patients. Based on this, we have selected potential therapeutic strategies that could be used in daily clinical practice.     

Quality-of-Life assessment for routine oncology clinical practice

Quality of life (QOL) is a concept that appears with ever-increasing frequency in the oncology literature. To date, QOL has largely centered on the research arena. Thus, many clinicians lack familiarity with the clinical utility of QOL measurement in clinical practice. Much work has been done on QOL in clinical trials. QOL data can be a useful predictor of patient response to treatment and survival and can affect decision-making about therapeutic options. Several randomized trials have shown the feasibility and benefits of QOL assessment in the clinical setting. Issues related to QOL data collection exist for those attempting to use QOL instruments within their practice. This review addresses the questions frequently asked by oncology care providers about the value of QOL assessment and issues related to it.     

Sleep disturbance in adults with cancer: a systematic review of evidence for best practices in assessment and management for clinical practice

Sleep disturbance is prevalent in cancer with detrimental effects on health outcomes. Sleep problems are seldom identified or addressed in cancer practice. The purpose of this review was to identify the evidence base for the assessment and management of cancer-related sleep disturbance (insomnia and insomnia syndrome) for oncology practice. The search of the health literature included grey literature data sources and empirical databases from June 2004 to June 2012. The evidence was reviewed by a Canadian Sleep Expert Panel, comprised of nurses, psychologists, primary care physicians, oncologists, physicians specialized in sleep disturbances, researchers and guideline methodologists to develop clinical practice recommendations for pan-Canadian use reported in a separate paper. Three clinical practice guidelines and 12 randomized, controlled trials were identified as the main source of evidence. Additional guidelines and systematic reviews were also reviewed for evidence-based recommendations on the assessment and management of insomnia not necessarily in cancer. A need to routinely screen for sleep disturbances was identified and the randomized, controlled trial (RCT) evidence suggests benefits for cognitive behavioural therapy for improving sleep quality in cancer. Sleep disturbance is a prevalent problem in cancer that needs greater recognition in clinical practice and in future research.     

Essence of evidence-based medicine: A case report.

PURPOSE: To illustrate the complexities of the evidence-based approach in clinical oncology practice and the implications for guidelines and evaluation of processes of care. PATIENT AND METHODS: A case report is presented in which a limited systematic review of the literature was used to address a specific clinical problem in an individual patient. Experts' opinions were also sought. RESULTS: A reasonable clinical decision was made by a participating patient based on indirect evidence of benefit that would be insufficient to support the same decision as a health policy in some jurisdictions. CONCLUSION: The practice of evidence-based oncology requires clinical judgment about the validity and applicability of research evidence. The factors that influence an evidence-based decision in the clinical context differ from those in the broader policy context, which could lead to legitimate differences in recommendations based on the same information. Used properly, the individual case report can be a powerful tool to illustrate complex clinical decision phenomena.