ReviewWhat has the meta-analysis contributed to today's standard of care in the treatment of thoracic malignancies?
Introduction
Meta-analysis is a methodological technique allowing to obtain a quantitative synthesis of the numerical results of the outcomes of trials (usually, almost exclusively, randomised controlled trials), using standardised and agreed statistical methods. This kind of study can be necessary because the treatments effects are modest and that there are a need of huge number of patients to have statistically significant results. Three kinds of meta-analyses can be realised: systematic review of the literature with meta-analysis, isolated meta-analysis of literature and individual data meta-analysis. The systematic review of the literature is a methodological review, which analyse exhaustively the literature in order to respond to a precise question. The available data are qualitatively and quantitatively analysed. If the studies are homogeneous, the results aggregation is possible and the quantitative analysis is called meta-analysis. We call this type of study meta-analysis and systematic review of literature (MASRL). In the isolated meta-analysis (IMA), the literature is reviewed in order to respond to one question directed on the aggregation of the available results. There is no qualitative analysis but the meta-analysis must integrate all the publications available in the literature. In the individual data meta-analysis (IDMA), the data of each patient included in each study are collected, results are updated and finally results are aggregated [1].
The place of meta-analyses is becoming important in thoracic oncology as well as in epidemiology, aetiology, diagnostic, prognosis as in treatment. This review will only focus on the contribution of meta-analyses (published in medical journals) in the treatment of non-small cell lung cancer (NSCLC), small cell lung cancer (SCLC) and mesothelioma. Meta-analyses were identified by an electronic search on the Medline data base, completed by a manual search in the articles. Only meta-analyses published in French, English, Spanish, Dutch and German were taken into account.
Section snippets
Resectable non-metastatic non-small cell lung cancer
Different questions have been studied by meta-analyses: the role of surgery, adjuvant and neoadjuvant chemotherapy and the role of postoperative radiotherapy, the role of radical chemoradiotherapy, the role of induction chemotherapy before radiotherapy and the role of sensitive chemotherapy (Table 1).
Role of thoracic irradiation + chemotherapy in limited disease
Three meta-analysis have demonstrated that thoracic radiotherapy improves survival in patients with limited small-cell lung cancer who are treated with combination chemotherapy [39], [40], [41] (Table 3). However, the heterogeneity between the individual studies is important and the techniques of radiotherapy and chemotherapies regimens are old.
Timing of thoracic irradiation in case of radio-chemotherapy in limited disease
The available randomised trial data support early concurrent chest radiotherapy with systemic chemotherapy in the management of limited-stage small cell
Mesothelioma
A systematic review with meta-analysis of the literature suggests that the most active chemotherapeutic regimen, in term of objective response rate, is the combination of cisplatin and doxorubicin and the best single-agent is cisplatin [53].
Discussion
Meta-analyses has been used as an effective tool for resolving various clinical questions, providing more reliable evidence for some clinical practice: (neo)adjuvant chemotherapy after surgery for resectable NSCLC, radio-chemotherapy for patients with unresectable limited NSCLC and limited SCLC, advantage of chemotherapy for advanced NSCLC and identification of the most active drugs. However, it should be noted that if meta-analyses are needed it is because the treatments effects are modest and
Conflict of interest
We have no conflict of interest.
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Quality indicators for non-small cell lung cancer operations with use of a modified Delphi consensus process
2014, Annals of Thoracic SurgeryGlobal lung oncology branch trial 3 (GLOB3): Final results of a randomised multinational phase III study alternating oral and i.v. vinorelbine plus cisplatin versus docetaxel plus cisplatin as first-line treatment of advanced non-small-cell lung cancer
2009, Annals of OncologyCitation Excerpt :This meta-analysis suffers from the heterogeneity of the studies included in the analysis and therefore difficulties arise in resolving the differences among patient population, or among the methods of assessment of the factors. Therefore, the true theoretical HR that we are trying to globally estimate in the meta-analysis from the included studies may vary from one study to another [32]. For instance, based on current available data on a large randomised trial conducted by Fossella et al. [4] comparing platinum-based doublets with NVB or DCT, the differences between these two doublets were mostly related to their safety profile and not conclusively related to any real differences in efficacy.
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