title: A comparison of epidural analgesia and traditional pain management effects on survival and cancer recurrence after colectomy: a population-based study.
abstract: BACKGROUND
  Cancer recurrence after surgery may be affected by immunosuppressive factors such as surgical stress, anesthetic drugs, and opioids. By limiting exposure to these, epidural analgesia may enhance tumor surveillance. This study compared survival and cancer recurrence rates for resection of colorectal cancer between patients who received perioperative epidurals and those who did not.
  
  
  METHODS
  The linked Medicare-Surveillance, Epidemiology, and End Results database was used to identify patients ages 66 yr or older with nonmetastatic colorectal cancer diagnosed between 1996 and 2005 who underwent open colectomy. Recurrence was defined as chemotherapy 16 months or more after surgery and/or radiation 12 months or more after surgery. Patients were followed for at least 4 yr. To account for hospital effects, overall survival was estimated via marginal Cox regression. Recurrence was estimated by conditional logistic regression.
  
  
  RESULTS
  A cohort of 42,151 patients, of whom 22.9% (n = 9,670) had epidurals at the time of resection, was identified. 5-yr survival was 61% in the epidural group and 55% in the nonepidural group. There was a significant association between epidural use and improved survival (adjusted Cox model hazard ratio = 0.91, 95% CI = [0.87, 0.94]). Adjusting for covariates, there was no significant reduction of recurrence in the epidural group (odds ratio = 1.05, 95% CI = [0.95, 1.15]). Several covariates, including blood transfusion, were predictive of mortality and cancer recurrence.
  
  
  CONCLUSIONS
  This large cohort study found that epidural use is associated with improved survival in patients with nonmetastatic colorectal cancer undergoing resection but does not support an association between epidural use and decreased cancer recurrence.
authors.affiliation: Department of General Anesthesiology, Anesthesiology Institute, Cleveland Clinic, Cleveland, Ohio 44195, USA. cummink2@ccf.org
authors.forename: Kenneth C
authors.initials: KC
authors.lastname: Cummings
authors.forename: Fang
authors.initials: F
authors.lastname: Xu
authors.forename: Linda C
authors.initials: LC
authors.lastname: Cummings
authors.forename: Gregory S
authors.initials: GS
authors.lastname: Cooper
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D015360:Analgesia, Epidural / Q000379:methods*; D015331:Cohort Studies; D003082:Colectomy; D015179:Colorectal Neoplasms / Q000401:mortality* / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000401:mortality* / Q000517:prevention & control; D059408:Pain Management / Q000379:methods*; D011159:Population Surveillance / Q000379:methods; D015996:Survival Rate / Q000639:trends; D016896:Treatment Outcome