Aim
Health Technology Wales sought to evaluate the clinical and cost‐effectiveness of contact X‐ray brachytherapy (CXB) for early‐stage rectal cancer.
Methods
Relevant studies were identified through ...systematic searches of MEDLINE, Embase, Cochrane Library and Scopus. A cost‐utility model was developed to estimate the cost‐effectiveness of CXB in National Health Service Wales, using results of the Organ Preservation in Early Rectal Adenocarcinoma (OPERA) trial. Patient perspectives were obtained through the Papillon Patient Support group and All‐Wales Cancer Network.
Results
The OPERA randomized controlled trial showed that CXB improved complete response and organ preservation rates compared with external‐beam boost for people with T2–3b, N0–1, M0 rectal cancer who are fit for surgery. Managing more of this population non‐operatively after CXB was estimated to provide 0.2 quality‐adjusted life years at an additional cost of £887 per person. CXB was cost effective compared with external‐beam boost at a cost of £4463 per quality‐adjusted life year gained. This conclusion did not change in scenario analysis and CXB was cost effective in 91% of probabilistic sensitivity analyses. Patients valued receiving clear information on all available options to support their individual treatment choices. The detrimental impact of a stoma on quality of life led some patients to reject the idea that surgery was their only option.
Conclusion
This evidence review and cost‐utility analysis indicates that CXB is likely to be clinically and cost effective, as part of a watch and wait strategy for adults fit for surgery. Wider access to CXB is supported by patient testimonies.
A 45-year-old man presented with a large para-aortic retroperitoneal tumour, a smaller second mediastinal tumour and elevated lactate dehydrogenase (LDH). Biopsy established a diagnosis of ...extragonadal seminoma. Treatment with cisplatin and etoposide resulted in complete resolution of the mediastinal mass, reduction of the size of the retroperitoneal mass and normalisation of LDH. Postchemotherapy positron emission tomography (PET) scan showed a small residual focus of uptake in the retroperitoneal mass and an unexpected focus in the left side of the neck. This was initially thought to represent residual active disease, but an ultrasound (US) scan and US-guided core biopsy of a cervical lymph node demonstrated metastatic papillary thyroid cancer rather than seminoma. A small (1 cm) primary papillary tumour in the thyroid was identified subsequently. The patient received consolidation radiotherapy to the retroperitoneum and underwent total thyroidectomy and neck dissection followed by radio-iodine treatment. He is currently in complete remission from both cancers.
A 45-year-old man presented with a large para-aortic retroperitoneal tumour, a smaller second mediastinal tumour and elevated lactate dehydrogenase (LDH). Biopsy established a diagnosis of ...extragonadal seminoma. Treatment with cisplatin and etoposide resulted in complete resolution of the mediastinal mass, reduction of the size of the retroperitoneal mass and normalisation of LDH. Postchemotherapy positron emission tomography (PET) scan showed a small residual focus of uptake in the retroperitoneal mass and an unexpected focus in the left side of the neck. This was initially thought to represent residual active disease, but an ultrasound (US) scan and US-guided core biopsy of a cervical lymph node demonstrated metastatic papillary thyroid cancer rather than seminoma. A small (1 cm) primary papillary tumour in the thyroid was identified subsequently. The patient received consolidation radiotherapy to the retroperitoneum and underwent total thyroidectomy and neck dissection followed by radio-iodine treatment. He is currently in complete remission from both cancers.
Aims
To estimate the association of longitudinal patterns of e‐cigarette use with cigarette smoking abstinence, after accounting for time‐dependent confounding and selection bias.
Design
Secondary ...analysis of longitudinal national cohort data. Using marginal structural models and four waves of the population assessment of tobacco and health (wave 1, 2013–14; wave 2, 2014–15; wave 3, 2015–16; wave 4, 2016–18), we estimated the association of vaping frequency across waves 2 and 3 with 12‐month sustained cigarette smoking abstinence at wave 4, adjusting for time‐dependent confounders at waves 1 and 2 and selection bias due to drop‐out with inverse probability of treatment and censoring weights.
Setting
United States.
Participants/cases
A total of 5699 adults (18+ years) who smoked cigarettes and did not vape at wave 1.
Measurements
The exposure was vaping frequency at waves 2 and 3 (non‐use, non‐daily use, daily use), representing nine possible combinations of vaping frequency across two waves. Non‐use at both waves was the exposure reference group. The primary outcome was sustained 12‐month cigarette smoking abstinence at wave 4.
Findings
Among 5699 adults who smoked cigarettes at wave 1, a total of 560 (9.8%) reported smoking abstinence at wave 4. Compared with nonuse at both waves, daily vaping at both waves risk ratio (RR) = 3.82, 95% confidence interval (CI) = 2.59–5.64 and non‐use at wave 2 followed by daily vaping at wave 3 (RR = 2.50, 95% CI = 1.66–3.77) were positively associated with smoking abstinence; non‐daily vaping at both waves was inversely associated with smoking abstinence (RR = 0.28, 95% CI = 0.11–0.75). Results persisted after accounting for misclassification of e‐cigarette use and cigarette smoking abstinence and after restricting to participants with plans to quit smoking.
Conclusions
In a US cohort of adult smokers, longitudinal patterns of vaping frequency appear to predict smoking abstinence, even after accounting for several sources of systematic error. Consistent daily vaping is associated with increased chances of cigarette smoking abstinence, while consistent non‐daily vaping is associated with decreased chances of smoking abstinence.
Youth e-cigarette use is associated with the initiation of combustible cigarette smoking, but prior studies have rarely accounted for time-varying measures of e-cigarette exposure or time-dependent ...confounding of e-cigarette use and smoking initiation.
Using five waves of the Population Assessment of Tobacco and Health (2013-2019), we estimated marginal structural models with inverse probability of treatment and censoring weights to examine the association between time-varying e-cigarette initiation and subsequent cigarette smoking initiation among e-cigarette- and cigarette-naïve youth (12-17 years) at baseline. Time-dependent confounders used as predictors in inverse probability weights included tobacco-related attitudes or beliefs, mental health symptoms, substance use, and tobacco-marketing exposure.
Among 9,584 youth at baseline, those who initiated e-cigarettes were 2.4 times as likely to subsequently initiate cigarette smoking as youth who did not initiate e-cigarettes (risk ratio = 2.4, 95% confidence interval CI = 2.1, 2.7), after accounting for time-dependent confounding and selection bias. Among youth who initiated e-cigarettes, more frequent vaping was associated with greater risk of smoking initiation (risk ratio ≥3 days/month = 1.8, 95% CI = 1.4, 2.2; 1-2 days/month = 1.2; 95% CI = 0.93, 1.6 vs. 0 days/month). Weighted marginal structural model estimates were moderately attenuated compared with unweighted estimates adjusted for baseline-only confounders. At the US population level, we estimated over half a million youth initiated cigarette smoking because of prior e-cigarette use over follow-up.
The association between youth vaping and combustible cigarette smoking persisted after accounting for time-dependent confounding. We estimate that e-cigarette use accounts for a considerable share of cigarette initiation among US youth. See video abstract at, http://links.lww.com/EDE/B937.
PDF
