Taxane monotherapy regimens for the treatment of recurrent epithelial ovarian cancer

  • Major change
  • Protocol
  • Intervention

Authors


Abstract

This is a protocol for a Cochrane Review (Intervention). The objectives are as follows:

To assess the efficacy and toxicity of different taxane monotherapy regimens for women with recurrent epithelial ovarian, tubal or primary peritoneal cancer.

Background

Description of the condition

Ovarian cancer is the seventh most frequent cancer diagnosis worldwide, with 238,700 new cases in 2012, and the eighth leading cause of cancer mortality, with 151,900 deaths (Coburn 2017). In the UK there were 7378 cases and 4128 deaths from ovarian cancer in 2014 (Cancer Research UK). A woman's risk of developing ovarian cancer before the age of 75 is estimated to range from 0.5% in low- and middle-income countries to 1% in high-income countries (Jemal 2011). In Europe, almost two-thirds of women with ovarian cancer die within five years after diagnosis (EUROCARE 2003), largely because most are diagnosed when the cancer is already at an advanced stage (Jemal 2008).

There is now substantial convincing evidence in support of the fallopian tube epithelium as the source of the cell of origin of low- and high-grade serous ovarian cancer (Vang 2013). Therefore, most new clinical trials of ovarian cancer include women with tubal and primary peritoneal cancers (Osman 2016). First-line therapy for women with ovarian cancer consists of a combination of cytoreductive surgery and platinum-based chemotherapy. Paclitaxel became the preferred partner to platinum chemotherapy after successful clinical trials in 1996 (McGuire 1996; Vermorken 2001); and it is estimated that in the UK 75% of women with ovarian cancer receive platinum‒paclitaxel frontline therapy (NICE 2003). The remaining 25% of women receive only a platinum agent for frontline therapy, primarily due to concerns of greater toxicity with the combined platinum‒paclitaxel regimen (NICE 2003). This approach achieves complete clinical remission in the majority of women; however, more than 50% will experience a relapse and require further chemotherapy (Ozols 2006). The consensus indicates that women whose cancer progresses while being treated with platinum chemotherapy or within four weeks of the last platinum dose are classed as platinum refractory; women who relapse within six months of completing platinum-based therapy are platinum resistant; those who relapse between 6 and 12 months are partially platinum sensitive; those who relapse 12 or more months later are platinum sensitive (Friedlander 2011). In general, those women who have platinum-sensitive ovarian cancer have a much better prognosis than patients who experience an early, platinum-resistant relapse (Stordal 2007a; Stordal 2007b).

Description of the intervention

There is currently no single agent recommended in the UK for the treatment of women with recurrent epithelial ovarian cancer who have been previously treated with platinum-based chemotherapy. Paclitaxel, topotecan, pegylated liposomal doxorubicin hydrochloride, trabectedin and gemcitabine are all licensed for use as single agents at the discretion of clinicians, following discussion with the women as to potential side effects (NICE 2003; NICE 2016). Paclitaxel, in combination with platinum or as monotherapy, is recommended as an option for treating recurrent ovarian cancer (NICE 2016). However, there is no guidance on the use of docetaxel in recurrent ovarian cancer.

How the intervention might work

The major mechanism of action of platinum-based chemotherapy drugs is binding to DNA, which hinders DNA replication and triggers apoptosis (programmed cell death) (Stordal 2007c). Taxanes, of which two examples are paclitaxel and docetaxel, cause cytotoxicity by binding to and stabilising polymerised microtubules and preventing cell division (Jordan 2004). Additionally, at low concentrations both paclitaxel and docetaxel have been shown to be anti-angiogenic (inhibiting the development of new blood vessels) in preclinical cell models (Grant 2003; Vacca 2002). Due to their differing mechanisms of action platinum agents and taxanes are often combined in cancer therapy. However, preclinical research in cell lines suggests that alternating between the two classes of drugs may be beneficial (Busschots 2015; Stordal 2007a). When platinum resistance occurs cancer cell lines are likely to have no change in resistance to taxanes and some cells even become more sensitive to taxanes.

The majority of studies comparing paclitaxel to docetaxel in ovarian cancer have been first-line studies in combination with platinum agents. These studies have shown similar efficacy between the two taxanes but different adverse effect profiles (Hsu 2004; Vasey 2004). Paclitaxel carries a higher rate of neurotoxicity, whereas docetaxel has been associated with a higher rate of neutropenia (low white blood cell count) (Hsu 2004; Vasey 2004). The efficacy and toxicities of taxanes is dependent on the dosing schedule and consequent differences in pharmacokinetics and pharmacodynamics. Neutropenia in response to paclitaxel treatment was found not to be related to plasma peak concentrations or areas under the curve but rather the duration of time that plasma concentrations were greater than 50 nM (Gianni 1995).

It is therefore important to investigate the schedule of administration of taxanes as salvage therapy. A recent study has suggested that weekly paclitaxel was superior to three-weekly paclitaxel in terms of survival benefits, quality of life, and toxicity in platinum-resistant ovarian cancer (Osman 2016). In the UK 3-weekly paclitaxel is the licensed regimen, but it is established clinical practice to use weekly paclitaxel for treating platinum-resistant disease (NICE 2016).

Why it is important to do this review

The most effective and tolerable regimen of taxane monotherapy in recurrent epithelial ovarian cancer has yet to be established. In addition, findings from a 2007 systematic review suggested that an improved response to paclitaxel salvage therapy might occur in women who receive paclitaxel as part of first-line therapy compared with those who do not (Stordal 2007a); however this finding remains uncertain. An up-to-date systematic review of the literature is therefore needed to guide the use of taxanes for recurrent epithelial ovarian cancer.

Objectives

To assess the efficacy and toxicity of different taxane monotherapy regimens for women with recurrent epithelial ovarian, tubal or primary peritoneal cancer.

Methods

Criteria for considering studies for this review

Types of studies

We will include randomised controlled trials (RCTs).

Types of participants

Adult women (aged 18 and over) diagnosed with epithelial ovarian, tubal or primary peritoneal cancer (FIGO stage I to IV), previously treated with platinum-based chemotherapy, and with recurrent disease.

Types of interventions

We will include trials comparing two or more taxane monotherapy regimens.

We will exclude trials comparing taxane monotherapy to combination chemotherapy; trials using other chemical derivatives of taxanes, such as taxanes bound to proteins or nanoparticles; and trials of maintenance chemotherapy for women following front-line cancer treatment with no evidence of recurrence.

Types of outcome measures

Primary outcomes
  • Overall survival (OS): survival until death from all causes. We will assess survival from the time when women are enrolled in the study.

  • Response rate: the sum of complete and partial responders as defined by a standardised response criterion such as Response Evaluation Criteria in Solid Tumours (RECIST) or that of the World Health Organization (WHO) (Litière 2016; Park 2003).

Secondary outcomes
  • Progression-free survival (PFS): survival until progression of disease. We will assess survival from the time when women are enrolled in the study.

  • Neurotoxicity (Grade 3 to 4)

  • Neutropenia (Grade 3 to 4)

  • Alopecia (Grade 3 to 4)

  • Quality of life, measured using a scale that has been validated through reporting of norms in a peer-reviewed publication.

We will present a 'Summary of findings' table reporting the following outcomes listed in order of priority:

  • OS

  • Response rate

  • PFS

  • Neurotoxicity (Grade 3 to 4)

  • Neutropenia (Grade 3 to 4)

  • Alopecia (Grade 3 to 4)

  • Quality of life

Timing of outcome assessment

For time-to-event data (OS and PFS) our preferred method of outcome assessment is to extract the hazard ratio and its confidence interval from the Kaplan‒Meier curves in each study. However, should data be presented as a percentage of women our chosen time points are 12 months for PFS and 24 months for OS.

Search methods for identification of studies

There will be no language or date restrictions for our searches. We will search for papers in all languages and have them translated as necessary.

Electronic searches

We will search the following electronic databases.

  • Cochrane Central Register of Controlled Trials (CENTRAL; latest issue in the Cochrane Library);

  • MEDLINE (1946 to present);

  • Embase (1980 to present);

  • PubMed (1996 to present).

We present the MEDLINE search strategy in Appendix 1.

For databases other than MEDLINE we will adapt the search strategy accordingly.

Searching other resources

We will identify all relevant articles on PubMed (ncbi.nlm.nih.gov/pubmed) and we will make a further search for newly published articles using the 'related articles' feature.

Unpublished and grey literature

We will search the following for ongoing trials.

If through these searches we identify ongoing trials that have not been published, we will approach the principal investigators and major co-operative groups active in this area, to ask for relevant data.

Handsearching

We will handsearch the citation lists of included studies. We will also handsearch the reports of conferences from the following sources. The date range of our searches will be 1983 to present as the first clinical trials of paclitaxel started in 1983 (Donehower 1996).

  • Gynecologic Oncology (Annual Meeting of the American Society of Gynecologic Oncology);

  • International Journal of Gynecological Cancer (Annual Meeting of the International Gynecologic Cancer Society);

  • British Journal of Cancer;

  • British Cancer Research Meeting;

  • Annual Meeting of European Society of Medical Oncology (ESMO);

  • Annual Meeting of the American Society of Clinical Oncology (ASCO).

Data collection and analysis

Selection of studies

We will download all titles and abstracts retrieved by electronic searching to the reference management database Endnote X8, and remove duplicates. Two review authors (BS, NH) will examine the remaining references independently. We will exclude those studies that clearly do not meet the inclusion criteria, and obtain copies of the full text of potentially relevant references. Independently, two review authors (BS, NH) will assess the eligibility of the retrieved reports/publications. We will resolve any disagreement through discussion or, if required, we will consult a third person (RK). We will identify and exclude duplicate reports and collate multiple reports of the same study so that each study rather than each report is the unit of interest in the review. We will record the selection process in sufficient detail to complete a PRISMA flow diagram and a 'Characteristics of excluded studies' table (Liberati 2009).

Potential reasons for exclusion of studies that appear eligible are as follows.

  • Includes a mixture of cancer types where ovarian cancer cannot be extracted.

  • Includes non-epithelial ovarian cancer where epithelial ovarian cancer cannot be extracted.

  • Includes women with epithelial ovarian cancer who have not relapsed after first-line therapy.

  • The study is not a RCT.

Data extraction and management

Independently, two review authors (BS, NH) will extract study characteristics and outcome data from included studies onto a piloted data collection form. We will note in the 'Characteristics of included studies' table if outcome data were not reported in a usable way. We will resolve disagreements by consensus or by involving a third person (RK). One review author (BS) will transfer data into the Review Manager 5 (RevMan 5) software (Review Manager 2014). We will double-check that data has been entered correctly by comparing the data presented in the systematic review with the study reports. A second review author (NH) will 'spot-check' the accuracy of the study characteristics against the trial report.

For included studies, we will extract the following data.

  • Author, year of publication and journal citation (including language)

  • Participating countries

  • Start and end date of patient enrolment

  • Study design

  • Study population

    • Total number enrolled, total number eligible and total number treated

    • Age (median)

    • Number of previous regimens of chemotherapy (dichotomised 1 or 2; and ≥ 3)

    • FIGO stage FIGO stage (dichotomised I or II; and III or IV)

    • Performance status (dichotomised 0 to 2; and ≥ 3)

    • Histology (dichotomised serous or non-serous)

    • Taxane pre-treatment status (dichotomised naive or pre-treated; women recruited prior to 1995 will be assumed to be taxane naive)

    • Platinum resistance status (dichotomised platinum resistant or sensitive; platinum refractory participants will be included with resistant)

  • Intervention details

    • Taxane

    • Treatment Interval

    • Dose of drug

    • Method of administration

  • Risk of bias in study (see below)

  • Duration of follow-up

  • Outcomes: for each outcome, we will extract the outcome definition and unit of measurement (if relevant). For adjusted estimates, we will record variables adjusted for analyses.

  • Results: we will extract the number of participants allocated to each intervention group, the total number analysed for each outcome, and the missing participants.

  • Notes: funding for trial, and notable conflicts of interest of trial authors.

Results will be extracted as follows:

  • For time-to-event data (survival and disease progression), we will extract the hazard ratio (HR) and 95% confidence interval (CI) and then convert these to a log(HR) using RevMan 5. If the 95% CI is not reported, we will attempt to estimate the log(HR) and its standard error using the methods of Parmar 1998 and Tierney 2007.

  • For dichotomous outcomes (e.g. adverse events or deaths, if it is not possible to use a hazard ratio) we will extract the number of participants in each treatment arm who experienced the outcome of interest and the number of participants assessed at endpoint, in order to estimate a risk ratio.

  • For continuous outcomes (e.g. QoL measures), we will extract the final value and standard deviation of the outcome of interest and the number of participants assessed at endpoint in each treatment arm at the end of follow-up, in order to estimate the mean difference between treatment arms and its standard error.

If reported, we will extract both unadjusted and adjusted statistics. Where possible, all data extracted will be those relevant to an intention-to-treat analysis, in which we will analyse participants in the groups to which they were assigned. We will note the time points at which outcomes were collected and reported.

Dealing with duplicate and companion publications

In the event of duplicate publications, companion documents or multiple reports of a primary study, we will maximise yield of information by collating all available data and use the most complete dataset aggregated across all known publications. In case of doubt, we will give priority to the publication reporting the longest follow-up associated with our primary or secondary outcomes. If possible, we will combine study references under the overall trial ID.

Assessment of risk of bias in included studies

We will assess and report on the methodological risk of bias of included studies in accordance with the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011), which recommends the explicit reporting of the following individual elements for RCTs (Appendix 2).

  1. Selection bias: random sequence generation and allocation concealment

  2. Performance bias: blinding of participants and personnel (i.e. treatment providers)

  3. Detection bias: blinding of outcome assessment

  4. Attrition bias: incomplete outcome data

  5. Reporting bias: selective reporting of outcomes

  6. Other possible sources of bias such as the source of funding for the study

Two review authors (BS, NH) will apply the 'Risk of bias' tool independently and resolve differences by discussion or by appeal to a third review author (RK). We will judge each item as being at high, low or unclear risk of bias as set out in the criteria provided by Higgins 2011, and provide a quote from the study report or a statement (or both) as justification for the judgement for each item in the 'Risk of bias' table. We will summarise results in both a 'Risk of bias' graph and a 'Risk of bias' summary. When interpreting treatment effects and meta-analyses, we will take into account the risk of bias for the studies that contribute to that outcome. Where information on risk of bias relates to unpublished data or correspondence with a trialist, we will note this in the 'Risk of bias' table.

We define the following endpoints as subjective outcomes: progression-free survival, response, neurotoxicity, quality of life.

We define the following endpoints as objective outcomes: overall survival, neutropenia.

Measures of treatment effect

We will use the following measures of the effect of treatment.

  • For time-to-event data, we will use the hazard ratio, if possible.

  • For dichotomous outcomes, we will analyse data based on the number of events and the number of women assessed in the intervention and comparison groups. We will use these to calculate the risk ratio (RR) and 95% confidence interval (CI).

  • For continuous outcomes, we will analyse data based on the mean, standard deviation (SD) and number of women assessed for both the intervention and comparison groups to calculate mean difference (MD) between treatment arms with a 95% CI. If the MD is reported without individual group data, we will use this to report the study results. If more than one study measures the same outcome using different tools, we will calculate the standardised mean difference (SMD) and 95% CI using the inverse variance method (Review Manager 2014).

We will undertake meta-analyses only where this is meaningful, i.e. if the treatments, participants and the underlying clinical question are similar enough for pooling to make sense. We will describe skewed data that are reported as medians and interquartile ranges narratively. Where multiple trial arms are reported in a single trial, we will include only the relevant arms. If two comparisons (e.g. drug A versus placebo and drug B versus placebo) are combined in the same meta-analysis, we will halve the control group in each case to avoid double-counting.

Unit of analysis issues

Two review authors (BS and NH) will review unit of analysis issues according to guidelines described in Higgins 2011 and resolve differences by discussion. These include reports where:

  • groups of women were randomised together to the same intervention (i.e. cluster-randomised trials);

  • individual women underwent more than one intervention (e.g. in a cross-over trial);

  • there are multiple observations for the same outcome (e.g. repeated toxicity measurements).

Dealing with missing data

We will attempt to contact study authors to obtain missing data (participant, outcome, or summary data). For participant data we will, where possible, conduct analysis on an intention-to-treat basis; otherwise we will analyse data as reported. We will report on the levels of loss to follow-up and assess this as a source of potential bias. For missing outcome or summary data we will not impute missing data.

Assessment of heterogeneity

Where we consider studies are similar enough, based on consideration of populations and interventions, to allow pooling of data using meta-analysis, we will assess the degree of heterogeneity by visual inspection of forest plots. If heterogeneity is such that we consider pooling data unlikely to be clinically meaningful, we will not perform a meta-analysis and will instead use a narrative approach. In this event we will investigate and report the possible clinical or methodological reasons for substantial heterogeneity. Clinical markers of patient heterogeneity that we intend to extract from each study are as follows.

  • Age (median)

  • Number of previous regimens of chemotherapy (dichotomised 1 or 2; and ≥ 3)

  • FIGO stage (dichotomised I or II; and III or IV)

  • Performance status (dichotomised 0-2 or 3+)

  • Histology (dichotomised serous or non-serous)

Assessment of reporting biases

If we include 10 or more studies that investigate a particular outcome, we will examine funnel plots corresponding to meta-analysis of the outcome to assess the potential for small-study effects such as publication bias. We plan to assess funnel plot symmetry visually; and if asymmetry is suggested, we will perform exploratory analyses to investigate it.

Data synthesis

If a sufficient number of clinically similar studies (in terms of participants, settings, intervention, comparison and outcome measures) are available to ensure meaningful conclusions and if statistical heterogeneity is low (I² < 30%), we will pool their results in meta-analyses using the fixed-effect model in Review Manager 2014. If statistical heterogeneity is substantial (I² > 30%) we will use the random-effects model with inverse variance for meta-analysis (DerSimonian 1986).

  • For time-to-event data, we will pool hazard ratios using the generic inverse variance facility in Review Manager 2014.

  • For any dichotomous outcomes, we will calculate the risk ratio (RR) and 95% confidence interval (CI) for each study and these will then be pooled.

  • For continuous outcomes, we will pool the mean differences (MD) with a 95% CI between the treatment arms at the end of follow-up, if all trials measure the outcome on the same scale; otherwise we will pool standardised mean differences (SMD).

If any trials have multiple treatment groups, we will divide the ‘shared’ comparison group into the number of treatment groups and treat the split comparison group as independent comparisons.

If we are unable to pool the data statistically using meta-analysis we will conduct a narrative synthesis of results. We will present the major outcomes and results, organised by intervention categories 'paclitaxel' or 'docetaxel'; and 'weekly administration' or '3-weekly administration'. Depending on the assembled research, we may also explore the possibility of organising the data by our identified participant subgroups of 'platinum resistant' or 'platinum sensitive'; and 'taxane naive' or 'taxane pre-treated'. Within the data categories we will explore the main comparisons of the review.

Main outcomes of 'Summary of findings' table for assessing the certainty of the evidence

The review's main outcomes in order of priority are:

  • overall survival (OS);

  • response rate;

  • progression-free survival (PFS);

  • neutropenia (Grade 3 to 4);

  • neurotoxicity (Grade 3 to 4);

  • quality of life.

We will present the overall certainty of the evidence for each outcome according to the GRADE approach, which takes into account issues not only related to internal validity (risk of bias, inconsistency, imprecision, publication bias) but also to external validity such as directness of results (Langendam 2013). We will create a 'Summary of findings' table(Appendix 3) based on the methods described in the Cochrane Handbook for Systematic Reviews of Interventions (Higgins 2011); and using GRADEPro GDT. We will use the GRADE checklist and GRADE Working Group certainty of evidence definitions (Meader 2014). We will downgrade the evidence from 'high certainty' by one level for serious (or by two for very serious) for each limitation, as follows.

  • High certainty: we are very confident that the true effect lies close to that of the estimate of the effect.

  • Moderate certainty: we are moderately confident in the effect estimate: the true effect is likely to be close to the estimate of the effect, but there is a possibility that it is substantially different.

  • Low certainty: our confidence in the effect estimate is limited: the true effect may be substantially different from the estimate of the effect.

  • Very low certainty: we have very little confidence in the effect estimate: the true effect is likely to be substantially different from the estimate of effect.

If meta-analysis is not possible we will present results in a narrative ‘Summary of findings’ table format, such as that used by Chan 2011.

Subgroup analysis and investigation of heterogeneity

We will perform subgroup analyses for the following factors: type of taxane; platinum-resistance status; and taxane pre-treatment status. We will consider factors such as age, FIGO stage, number of cycles of prior chemotherapy, performance status, histology, length of follow-up and risk of bias status in interpretation of any heterogeneity.

Sensitivity analysis

We will perform sensitivity analyses, excluding studies with a high risk of bias to determine the impact of these studies on the final outcome of the review.

Acknowledgements

We thank Dr. Donal O'Mathúna, an author of the previous version of this protocol. We thank Jo Morrison for clinical and editorial advice; Clare Jess for her contribution to the editorial process; and Jo Platt for help with designing the search strategy.

This project was supported by the National Institute for Health Research (NIHR), via Cochrane Infrastructure funding to the Cochrane Gynaecological, Neuro-oncology and Orphan Cancers Group. The views and opinions expressed herein are those of the authors and do not necessarily reflect those of the Systematic Reviews Programme, NIHR, National Health Service or the Department of Health, UK.

Appendices

Appendix 1. MEDLINE (Ovid) search strategy

1. exp Ovarian Neoplasms/
2. (ovar* adj5 (cancer* or neoplas* or carcinom* or malignan* or tumor* or tumour*)).mp.
3. 1 or 2
4. (Taxane* or Paclitaxel* or Taxol* or Docetaxel* or Taxotere* or anzatax* or asotax or bristaxol* or nsc*125973 or onxol* or paxene* or praxel* or RP56976 or BMS*181339 or BMS181339).ti,ab.
5. exp platinum/
6. (platin* or CDDP or DDP or cisplat* or cis-diammine* or cis-dichloro* or cis-platin* or peyrone* or carboplat* or CBDCA or JM-8 or paraplat* or platinex* or platino*).ti,ab.
7. 5 or 6
8. 3 and 4 and 7
9. randomized controlled trial.pt.
10. controlled clinical trial.pt.
11. randomized.ab.
12. placebo.ab.
13. clinical trials as topic.sh.
14. randomly.ab.
15. trial.ti.
16. (phase II or Phase III or Phase IV).ab.
17. 9 or 10 or 11 or 12 or 13 or 14 or 15 or 16
18. (animals not (humans and animals)).sh.
19. 17 not 18
20. 8 and 19

key: mp = title, original title, abstract, name of substance word, subject heading word, unique identifier; ab = abstract, ti = title, pt = publication type, sh = subject heading

Appendix 2. Risk of bias items

  • Random sequence generation

    1. Low risk of bias e.g. participants assigned to treatments on basis of a computer-generated random sequence or a table of random numbers

    2. High risk of bias e.g. participants assigned to treatments on basis of date of birth, clinic identity-number or surname, or no attempt to randomise participants

    3. Unclear risk of bias e.g. not reported, information not available

  • Allocation concealment

    1. Low risk of bias e.g. where the allocation sequence could not be foretold

    2. High risk of bias e.g. allocation sequence could be foretold by patients, investigators or treatment providers

    3. Unclear risk of bias e.g. not reported

  • Blinding of participants and personnel (NB: blinding of patients and treatment providers is usually possible only for pharmacological interventions)

    1. Low risk of bias, if participants and personnel were adequately blinded

    2. High risk of bias, if participants were not blinded to the intervention that the participant received

    3. Unclear risk of bias, if this was not reported or unclear

  • Blinding of outcomes assessors

    1. Low risk of bias, if outcome assessors were adequately blinded

    2. High risk of bias, if outcome assessors were not blinded to the intervention that the participant received

    3. Unclear risk of bias, if this was not reported or unclear

  • Incomplete outcome data: we will record the proportion of participants whose outcomes were not reported at the end of the study. We will code a satisfactory level of loss to follow-up for each outcome as:

    1. Low risk of bias, if fewer than 20% of patients were lost to follow-up and reasons for loss to follow-up were similar in both treatment arms

    2. High risk of bias, if more than 20% of patients were lost to follow-up or reasons for loss to follow-up differed between treatment arms

    3. Unclear risk of bias if loss to follow-up was not reported

  • Selective reporting of outcomes

    1. Low risk of bias e.g. review reports all outcomes specified in the protocol

    2. High risk of bias e.g. It is suspected that outcomes have been selectively reported

    3. Unclear risk of bias e.g. It is unclear whether outcomes had been selectively reported

  • Other bias

    1. Low risk of bias, if you do not suspect any other source of bias and the trial appears to be methodologically sound

    2. High risk of bias, if you suspect that the trial was prone to an additional bias

    3. Unclear risk of bias, if you are uncertain whether an additional bias may have been present.

Appendix 3. Draft 'Summary of findings table'

Example summary of findings table

Title:

Patient or population: Platinum pre-treated recurrent epithelial ovarian cancer

Settings: Hospital

Intervention: Taxane monotherapy

Comparison: Paclitaxel vs docetaxel; weekly vs 3-weekly

OutcomesIllustrative comparative risks*Relative effect (95% CI)

No of participants

(studies)

Certainty of evidence

(GRADE)

Comment
Assumed riskCorresponding risk
1 Overall Survival      
2 Response Rate      
3 Progression-Free Survival      
4 Neurotoxicity (Grade 3-4)      
5 Neutropenia (Grade 3-4)      
6 Alopecia (Grade 3-4)      
7 Quality of life      
*The basis for the assumed risk (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the
assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI).
CI: confidence interval; HR: hazard ratio; MD: mean difference; RR: risk ratio; OR: odds ratio
GRADE Working Group grades of evidence
High certainty: Further research is very unlikely to change our confidence in the estimate of effect.
Moderate certainty: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate.
Low certainty: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate.
Very low certainty: We are very uncertain about the estimate.

What's new

DateEventDescription
8 May 2018AmendedAuthor team amended and methodological sections revised.
9 April 2018New citation required and major changesProtocol revised to meet new methodological requirements before review development. Original protocol published Issue 10, 2010.

Contributions of authors

Britta Stordal developed the updated protocol from a previously published version (Stordal 2010). Neville Hall reviewed the manuscript and advised on methodology. Roshni Kalachand reviewed the manuscript and advised from a clinical perspective.

In the full review Britta Stordal and Neville Hall will perform the search strategy and data extraction with additional assistance from several students at Middlesex University. Britta Stordal will draft the review; Neville Hall will check all data analysis and review the manuscript for methodological issues. Roshni Kalachand will review the manuscript and offer advice from a clinical perspective as well resolving issues from the data extraction and risk of bias process.

Britta Stordal will be responsible for the review update.

Declarations of interest

Britta Stordal is employed by Middlesex University London and has worked on a contract basis for the Research Executive Agency reviewing grants. She has received grant funding from the Health Research Board in support of this review and from the Bone Cancer Trust in support of other projects. She has also received travel expenses from the National Institute for Health and Care Excellence (NICE) in her role as a specialist committee member.
Roshni Kalachand: none known
Neville Hall: none known

Sources of support

Internal sources

  • None, Other.

External sources

  • None, Other.

Ancillary