Introduction
Material and methods
Literature search
Outcome measures
Study selection
Inclusion criteria
Exclusion criteria
Data extraction
Statistical description
Results
Study selection
Included studies
Study designs
Patient characteristics
Study, year | Gynaecological patients (total number of pelvic patients) | Mean age (range) | Primary cancer diagnosis | Clinical symptoms | Outcome measures | Chamber | Pressure (ATA) | Sessions (n) | Time (min) |
---|---|---|---|---|---|---|---|---|---|
Oscarsson et al., 2013 [14] | 2 (39) | 71 (35–84) | Prostate (n = 34) Rectal (n = 3) Cervical (n = 2) | Cystitis and proctitis (bleeding from mucosa, pain in the pelvis region, incontinence, frequent and/or imperative urge for defecation and/or urination) | EPIC (urinary and bowel domain) | Multiplace (n = 35) Monoplace (n = 4) | \({2.4}^{\mathrm{a}}\) | 36 (mean) | 90 |
Glover et al., 2016 [15] | 38 (84) | Treatment group 62.3 Control group 62.0 | Prostate (n = 33) Anus (n = 8) Vagina (n = 4) Cervix (n = 22) Uterus (n = 11) Anal canal (n = 1) Vulvar (n = 1) Retroperitoneum (n = 1) Pelvis (n = 1) Rectum (n = 1) Bladder (n = 1) | Chronic bowel dysfunction (grade 1 or 2 gastrointestinal symptoms) | Bowel component of IBDQ score, IBDQ rectal bleeding score, LENT-SOMA score, CTCAE scale, EORTC QLQ-C30 questionnaire and QLQ-CR38 module | Monoplace and multiplace | 2.4 (treatment group) 1.3 (control group) | \({40}^{\mathrm{b}}\) | 90 |
Oscarsson et al., 2019 [16] | 20 (79) | Treatment group 64.0 (13.6 SD) Control group 64.8 (10.7 SD) | Cervical (n = 18) Prostate (n = 54) Rectum (n = 3) Uterus (n = 2) Other (n = 2) | Cystitis | EPIC (urinary and bowel), SF-36 score, histological changes in the urinary bladder biopsies and LRMGS grades | Multiplace and monoplace | 2.4–2.5 | 30–40 | 80—90 |
Oliai et al., 2012 [17] | 2 (15) | 69.5 (55–84) * | Prostate (n = 12) Cervical (n = 1) Vulvar (n = 1) Rectal (n = 1) | Cystitis | LENT-SOMA score, clinical recurrence and severity of hematuria | Monoplace | 2.0 | 24 (mean) * | 90–120 |
Sidik et al., 2007 [18] | 65 | Treatment group 47 (± 5.5 SD) Control group 44.7 (± 6.2 SD) | Cervical (n = 65) | Overall side effects | LENT-SOMA score and Karnofsky score | NR | 2.0–3.0 | \({>18}^{\mathrm{c}}\) | NR |
Clarke et al., 2008 [19] | 104 (120) | NR | Cervical (n = 93) Uterus (n = 10) Endometrium (n = 1) Prostate (n = 13) Colon (n = 1) Rectal (n = 2) | Proctitis | LENT-SOMA bowel function, SF-12 general health function survey, clinical evaluation and patients’ beliefs | NR | 2.0 | \({30}^{\mathrm{d}}\) | 90 |
Parra et al., 2011 [20] | 4 (25) | 66.7 (42–80) | Prostate (n = 20) Bladder (n = 1) Cervical (n = 3) Endometrium (n = 1) | Cystitis | Clinical response of macroscopic bleeding | Multiplace | 2.2 | 40 | 90 |
Rud et al., 2009 [21] | 16 | NR | Cervix (n = 14) Endometrium (n = 1) Ovarian (n = 1) | Overall tissue injuries (unacceptable pain in pelvic region) | BPI score, MADRS score, MRI, use of pain descriptors or analgesics and clinical changes | NR | 2.4 | 21 | 90 |
Safra et al., 2008 [22] | 11 (13) | 55.2 (32–82) * | Cervix (n = 8) Endometrium (n = 2) Vagina (n = 1) Rectal (n = 1) Bladder (n = 1) | Cystitis, proctitis, rectovaginal fistulas, vesicovaginal fistulas, vaginal ulcers and wound healing complications | NCI Common Toxicity Criteria and clinical changes of proctitis, cystitis and wound complications | Multiplace | 2.0 | 27 (mean) | 90 |
Jones et al., 2006 [23] | 6 (10) | 65 (39–79) | Prostate (n = 3) Cervix (n = 4) Uterus (n = 1) Rectum (n = 1) Vagina (n = 1) | Proctitis | LENT-SOMA score and clinical changes | NR | 2.0–2.5 | 36–41 | 90 |
Williams et al., 1992 [24] | 13 (14) | 53 (35–78) | Cervix (n = 9) Endometrium (n = 1) Vagina (n = 3) Colon (n = 1) | Necrotic wounds | Clinical changes of vaginal necrosis and fistula | NR | 2.0 | 44 (mean) | 90–120 |
Feldmeier et al., 1996 [25] | 30 (44) | 60.9 (33–80) * | Cervix (n = 19) Endometrium (n = 3) Vulva (n = 5) Ovarian (n = 2) Uterus (n = 1) Prostate (n = 1) Testicular (n = 2) Rectum/anus (n = 4) Bladder (n = 2) Ewings sarcoma (n = 1) Mycosis fungoides (n = 1) Unknown (n = 1) Skin (n = 1) Urethra (n = 1) | Overall injuries (necrotic wounds, fistulas, cystitis, enteritis colitis, caecal perforation, soft tissue and ulcers) | Clinical changes of healing injuries, closure of fistulas and necrotic wounds | Multiplace | 2.4 | 27.2 (mean) * | 90 |
Al-Ali et al., 2010 [26] | 3 (14) | Treatment group 73.5 (59–88) * Control group 51* | Prostate (n = 10) Colon (n = 1) Cervix (n = 1) Vulvar (n = 1) Uterus (n = 1) | Cystitis (macroscopic hematuria) | Clinical changes in hemorrhagic cystitis and bleeding | NR | 2.5 | 30 * | 60 |
Bui et al., 2004 [27] | 7 (45) | 64 (7–88) | Head and neck (n = 31) Pelvic (n = 7) Other (n = 7) | Overall side effects (osteoradionecrosis, soft tissue necrosis, proctitis and cystitis) | RTOG criteria | NR | 2.4 | 40 (median) * | 100 |
Andren et al., 2020 [28] | 7 (52) | 67.9 (SD 10.1) | Prostate (n = 41) Cervix (n = 4) Rectum (n = 3) Endometrium (n = 2) Bladder (n = 1) Vulvar (n = 1) | Proctitis and cystitis | LENT-SOMA score (bladder and bowel domain) | Multiplace and monoplace | 2.4 (multiplace) 2.0 (monoplace) | 31 (mean) | \({90}^{\mathrm{ e}}\) |
Ngoo et al., 2018 [29] | (18) | \({\begin{array}{c}59.5 \\ (42-82)\end{array}}^{\mathrm{f}}\) | NR | Cystitis | Clinical | NR | 2.4 | 27 (median) | 90 |
Lin et al., 2017 [30] | 39 (42) | 63 (42–82) | Cervix (n = 39) Urinary bladder (n = 3) | Acute hematuria, dysuria and urgency and frequency of urination | Clinical and cystoscopic findings | Multiplace | 2.5 | 38 (mean) | 120 |
Ribeiro de Oliveira et al., 2015 [31] | 108 (176) | 61.91 (15–85) | Cervix (n = 89) Prostate (n = 56) Endometrium (n = 17) Bladder (n = 7) Rectum (n = 3) Ewing’s sarcoma (n = 2) Ovarian (n = 1) Vulva (n = 1) | Cystitis | Resolution of macroscopic hematuria | Multiplace | 2.5 | 36.53 (mean) | 90 |
Mougin et al., 2016 [32] | 6 (71) | 72 (39–87) | Cervix (n = 6) Prostate (n = 61) Bladder (n = 2) Other (n = 2) | Cystitis | CTCAE scale, clinical changes | Multiplace | 2.5 | 29 (mean) | 90 |
Ferreira et al., 2014 [33] | 36 (70) | 66.5 (34–91) | Cervix (n = 34) Vagina (n = 2) Prostate (n = 30) Anus (n = 2) Rectum (n = 1) Colon (n = 1) | Cystitis, proctitis, enteritis, vaginitis, proctoenteritis | LENT-SOMA scale and clinical | Multiplace | 2.4 | 40 (median) | 80 |
Fink et al., 2006 [34] | 14 | 52.9 (34–77) | Cervix (n = 8) Vulvar (n = 1) Bartholin gland (n = 1) Vaginal (n = 1) Ovarian (n = 1) | Delayed radiation injuries | Clinical | NR | 2.4 | 32.8 (mean) | 90 |
Technical characteristics regarding HBOT
Time
Outcome measures
Patient reported outcome measures
Difference of reported studies
Results studies gynaecological malignancies
Study, year | Results | Significance level |
---|---|---|
Oliai et al., 2012 [17] | 50% (one out of two patients) time to bleeding recurrence after HBOT was 17 months and a reduction from persistent to intermittent hematuria was reported | NR |
50% (one out of two patients) time to bleeding recurrence after HBOT was 3 months. The patient had a recurrence from persistent to intermittent hematuria, was diagnosed subsequently with bladder cancer after HBOT and underwent 30 extra treatments | ||
0.89 mean reduction LENT-SOMA score | ||
Sidik et al., 2007 [18] | 43.41% LENT-SOMA difference between treatment and control group soon after intervention | p-value LENT-SOMA soon < 0.001 |
13.95% LENT-SOMA difference between treatment and control group six months after HBOT | p-value LENT-SOMA 6 months = 0.008 | |
15.14% Karnofsky difference between treatment and control group soon after intervention | p-value Karnofsky soon < 0.001 | |
12.80% Karnofsky difference between treatment and control group six months after HBOT | p-value Karnofsky 6 months = 0.007 | |
Parra et al., 2011 [20] | 100% (four out of four patients) complete resolution of macroscopic bleeding after HBOT | NR |
Rud et al., 2009 [21] | 50% of the patients reported some or good effect | NR |
50% of the patients experienced big changes such as major fractures and/or marked soft tissue oedema | ||
Insignificant difference in use or frequency of pain descriptors after HBOT, the use of analgesics, BPI or depression scale scores and MADRS after HBOT | ||
MR imaging showed signal abnormalities in 93.75% of the patients and a variety of changes was reported | ||
Safra et al., 2008 [22] | 100% resolution of macroscopic hematuria | |
100% resolution of scar complications | ||
3.0 points mean improvement of CTC change in cystitis and proctitis | p-value CTC score = 0.001 | |
2.8 points mean improvement of CTC change in recto-vaginal fistulas, vesico-vaginal fistulas and vaginal ulcers | ||
4.0 points mean improvement of CTC change in wound healing complications | ||
Williams et al., 1992 [24] | 92.9% of the patients had a complete recovery or improvement of necrosis and fistulas | NR |
Feldmeier et al., 1996 [25] | 61.3% of the patients recovered from the injuries after HBOT | NR |
6.5% of the patients did not recover from the injuries after HBOT | ||
25.8% of the patients received inadequate number of treatments and were all deceased | ||
6.5% of the patients were lost to follow-up | ||
Al-Ali et al., 2010 [26] | 100% (two out of two patients) reported no response in the treatment group to hemorrhagic cystitis | NR |
100% (one out of one patient) had spontaneous bleeding stop in the control group | ||
Fink et al., 2006 [34] | 71.4% of the patients recovered from delayed radiation injuries or improved more than 50% | NR |
14.3% of the patients (two patients) bleeding recurred after 10 and 11 months | ||
Highest success rate in patients with necrotic ulcers with 50% of the patients having complete healing and 50% of the patients achieving a 50% improvement |
Cystitis
Proctitis and overall bowel symptoms
Wound complications
Patient reported outcome measures
Results studies pelvic radiotherapy
Study, year | Percentage of gynaecological cancers | Results | Significance level |
---|---|---|---|
Oscarsson et al., 2013 [14] | 5.1% | Relative improvement of the EPIC score urinary domain immediately after treatment was 22% and after six to twelve months follow-up the relative improvement was 21% | p-value EPIC urinary score relative increase < 0.001 |
29% improvement EPIC score urinary domain in early state and after six to twelve months follow-up in patients with an EPIC score below eighty. In the patients with an EPIC score below eighty before HBOT, 76% of the patients improved after HBOT and 24% did not respond to HBOT | Improved EPIC score p-value < 0.001 | ||
31% of the patients reported an EPIC score above eighty after HBOT in the urinary domain | |||
Relative improvement EPIC score bowel domain immediately after treatment was 24% and after six to twelve months follow-up was 21% | p-value EPIC bowel score relative increase < 0.001 | ||
41% increasement of EPIC score bowel domain early after HBOT and 39% increasement of EPIC score bowel domain six to twelve months after HBOT in patients with an EPIC score below eighty | Improved EPIC score p-value < 0.001 | ||
89% of patients had an increase in EPIC score after HBOT and 11% of patients did not respond to HBOT in the patients with an EPIC score below eighty | |||
22% of the patients reported an EPIC score above eighty in the bowel domain | |||
Glover et al., 2016 [15] | 45.2% | Absolute difference between treatment group and control group in improvement of at least one point in IBDQ rectal bleeding score after twelve months: 7.6% | p-value absolute difference IBDQ-score = 0.58 95% CI = −20.3 to 35.5 |
Insignificant difference in improvement of overall bowel function after twelve months between treatment and control group (Mann–Whitney U-score: 0.67) | U-score bowel function p-value = 0.50 | ||
Insignificant difference in rectal bleeding after twelve months between treatment and control group (Mann-Whitney U-score: 1.69) | U-score rectal bleeding p-value = 0.092 | ||
The improvement from baseline to twelve months was consistent with the ITT analysis and differed with a U score of 0.71 for overall bowel function and a U score of 2.06 for rectal bleeding between the control and treatment group | U-score bowel function ITT p-value = 0.48 U-score rectal bleeding ITT p-value = 0.040 | ||
PP-analyses were consistent with the ITT analysis with a U score of 0.94 for overall bowel function and a U score of 1.44 for rectal bleeding | U-score bowel function PP p-value = 0.35 U-score rectal bleeding PP p-value = 0.15 | ||
LENT-SOMA rectal bleeding score: 100% of the patients increased in the control group and 31% of the patients increased in the treatment group | |||
Insignificant improvement in rectum and intestine LENT-SOMA score in the control and treatment group. The U-score of rectal LENT-SOMA was 1.62 and the U-score of intestinal LENT-SOMA was -1.41 | p-value U-score rectal = 0.11 p-value U-score intestinal = 0.16 | ||
No difference between treatment and control group in CTCAE grades after treatment | |||
Subgroup analyses reported that the IBDQ scores between the treatment and control group did not change in patients who had completed radiotherapy one to five years before HBOT | |||
The U score for overall bowel function was 0.59 and the U score for rectal bleeding was 1.57 | p-value bowel function = 0.56 p-value rectal bleeding = 0.12 | ||
Difference in rectal bleeding was reported in the subgroup analyses of patients treated in a monoplace chamber with a U score of 2.9. The difference for overall bowel function in the subgroup analyses of patients treated in a monoplace chamber was insignificant with a bowel function U score of -0.31 | p-value rectal bleeding monoplace = 0.004 p-value bowel function monoplace = 0.76 | ||
Oscarsson et al., 2019 [16] | 25.3% | 73% of the patients had an improvement, 23% of the patients did not change and 5% decreased in the treatment group of the EPIC total urinary score | |
34% of the patients had an improvement, 54% of the patients did not change and 11% decreased in the control group of the EPIC total urinary score | |||
40% of the patients in the treatment group and 9% of the patients in control group reported an EPIC score above eighty at the end of the study | |||
64% of the patients had an improvement, 28% of the patients did not change and 8% had decreased LRMGS grades in the treatment group | p-value differences between groups = 0.0012 | ||
18% of the patients had an improvement, 53% of the patients did not change and 29% had decreased LRMGS grades in the control group | |||
10.1 points significant difference in mean EPIC urinary total score between treatment and control group (ITT analysis) | 95% CI = 2.2–18.1 ITT analysis p-value = 0.013 | ||
11.4 points significant difference mean EPIC urinary total score between treatment and control group in urinary domain (PP analysis) | 95% CI = 3.5–19.2 PP analysis p-value = 0.0047 | ||
8.33 points significant difference mean EPIC bowel total score between treatment and control group | 95% CI = 1.15—15.54 p-value = 0.024 | ||
11.5 points significant difference in the EPIC sub score of urinary bother between treatment and control group | 95% CI = 2.7—20.3 p-value = 0.012 | ||
12.1 points significant difference in the EPIC sub score of urinary incontinence between treatment and control group | 95% CI = 4.3—19.9 p-value = 0.0031 | ||
Significant improvement in mean SF-36 score for general health in the treatment group of 13.2 points. | 95% CI SF-36 score = 6.0—20.4 p-value = 0.0006 | ||
No significant change in the control group for the mean SF-36 score | |||
Clarke et al., 2008 [19] | 86.7% | 88.9% of the patients recovered or experienced some improvement in the treatment group and 62.5% experienced some improvement in the control group. The calculated absolute difference was 26.4% | |
The treatment group reported significantly greater healing/improvement compared to the control group | Fisher’s exact test p = 0.0009 Logistic regression analysis p = 0.0011 | ||
2.39 points absolute difference in improvement of the LENT-SOMA score between treatment and control group. Improvement in treatment group was greater than in the control group | p-value absolute difference < 0.0001 greater decrease p-value = 0.0019 | ||
Treatment group had a lower mean score than the control group after initial allocation with a difference of 1.93 | 95% CI = 0.38–3.48 p-value difference in mean score = 0.0150 | ||
No differences were reported after the crossover | p-value after crossover = 0.6594 | ||
Odds ratio for some improvement was 5.93 | 95% CI = 2.04–17.24 | ||
Significant better outcomes were reported more often in the treatment group An absolute risk reduction of 0.32 (32%) was recorded in the clinical evaluation outcomes, which corresponds to a number needed to treat of 3 Improvement in treatment group for bowel bother was 14% and for bowel function 9%. Improvement in control group for bowel bother was 5% and for bowel function 6% The control group had an improvement of 13.6 for bowel bother and 10% for bowel function after cross-over | p-value Jockheere Terpstra = 0.0008 | ||
A significant improvement was reported between initialization and randomization in the treatment group for the bowel bother subscale with a change of 14.14 | p-value = 0.0007 | ||
The control group had an insignificant improvement between initialization and randomization for the bowel bother subscale with a change of 5.75 | p-value = 0.1521 | ||
The control group had a significant improvement after crossover with a change of 14.27 | p-value = 0.0002 | ||
Jones et al., 2006 [23] | 60.0% | 44.5% complete recovery of rectal bleeding, 33.3% decrease in frequency and severity of rectal bleeding 11.1% of the patients had a decrease in the rectal bleeding 60.0% rectal pain recovery and 20.0% of the patients reported an improvement in rectal pain 20.0% of the patients reported full recovery of diarrhea and 60.0% reported an improvement | NR |
Bui et al., 2004 [27] | NR | 100% overall improvement | NR |
Andren et al., 2020 [28] | 13.5% | Significant mean LENT-SOMA score reduction for all patients of 3.7 | 95% CI mean reduction = 2.6–4.8 p-value mean reduction < 0.001 |
Significant mean LENT-SOMA score reduction in the subgroup analysis for proctitis of 3.8 | 95% CI reduction proctitis = 1.4–6.10 p-value reduction proctitis = 0.004 | ||
Significant mean LENT-SOMA score reduction in the subgroup analysis for cystitis of 3.7 (2.4–5.0) | p-value reduction cystitis < 0.001 | ||
Significant association between severity of LRITT and improvement in LENT-SOMA scores | p-value severity of LRITT = 0.003 | ||
Insignificant association between improvement of LENT-SOMA scores and the number of treatments, number of comorbidities and age | p-value number of treatments = 0.71 p-value number of comorbidities = 0.50 p-value of age = 0.21 | ||
Ngoo et al., 2018 [29] | NR | The bleeding resolved in 77.8% of the patients | |
This percentage was associated with a shorter time between radiotherapy and the first cystitis episode and was associated with lower transfusion requirements before treatment | p-value interval = 0.018 p-value lower transfusion requirements = 0.012 | ||
Lin et al., 2017 [30] | 92.9% | Macroscopic hematuria resolved in 83.3% of the patients after an average of 38 sessions and macroscopic hematuria decreased in 7.1% of the patients | NR |
Three patients (7.1%) had frequent urination and urgency without significant hematuria, with symptoms resolved after HBOT | |||
One patient (2.4%) did not respond to HBOT | |||
One patient underwent an urodynamic test with the following results: urine peak flow from 12.8 ml/s before HBOT to 15.0 ml/s after HBOT, urine mean flow from 6.5 ml/s before HBOT to 8.9 ml/s after HBOT, urine voiding time of 40.0 s before HBOT to 28.0 s after HBOT, time to peak flow from 15.0 s before HBOT to 8.0 s after HBOT and voided volume from 251 mL before HBOT to 248 mL after HBOT | |||
Ribeiro de Oliveira et al., 2015 [31] | 61.4% | 67% of the patients recovered completely from hematuria and 22.7% of the patients recovered partially from hematuria 10.2% of the patients did not recover from hematuria of which 9.1% of these patients had an absence of variation of hematuria and 1.1% of these patients had aggravation of hematuria After a mean follow-up period of twelve months, the recurrence rate of hematuria was 15.2% | |
No significant difference of hematuria resolution between sex groups | p-value = 0.738 | ||
No significant difference in hematuria resolution between uterine cervix cancer patients and prostate cancer patients | p-value = 0.228 | ||
Significant difference for the need of transfusion support in the group with hematuria resolution and the group without hematuria resolution. 82.9% of the patients in the group with hematuria resolution did not use transfusion therapy and 61.1% of the patients in the group without hematuria resolution did not use transfusion therapy | p-value = 0.026 | ||
Insignificant difference in hematuria resolution depending on the differences in time between radiotherapy and hematuria, time between hematuria and HBOT and time between radiotherapy and HBOT | p-value radiotherapy and hematuria = 0.236 p-value hematuria and HBOT = 0.199 p-value radiotherapy and HBOT = 0.44 | ||
Significant difference in hematuria resolution depending on the number of treatments | p-value number of treatments = 0.042 | ||
Mougin et al., 2016 [32] | 8.5% | Haematuria had completely resolved in 52.1% of the patients In 12.7% of the patients, haematuria had partially resolved No improvement was registered in 35.2% of the patients 26.8% of the patients had a recurrence of haematuria after a median follow-up of 15 months, of which 9 patients received a second HBOT course that helped 8 patients At 1 year, the haematuria-free survival rate was 70% | |
The hematuria grade of less than 3 made a significant difference for successful therapeutic outcome with a hazard ratio of 4.4 (univariate analysis) | p-value = 0.01 | ||
The hematuria grade of less than 3 at the time of diagnosis made a significant difference for successful therapeutic outcome with a hazard ratio of 3.6 (multivariate analysis) | p-value = 0.027 | ||
The anticoagulant therapy made a significant difference for treatment failure with a hazard ratio of 0.3 | p-value = 0.03 | ||
Ferreira et al., 2014 [33] | 51.4% | The response rate of resolution or improvement of haematuria after a median follow-up period of 55.5 months was 91.4% | |
Haematuria persisted in 6 patients, of which 5 patients had undergone cystectomy | |||
Median difference in subjective score of dysuria before and after HBOT was 1 (1–1.5) | p-value < 0.001 | ||
Median difference in subjective score of frequency before and after HBOT was 0.5 (0.5–1.5) | p-value = 0.016 | ||
Median difference in subjective score of haematuria before and after HBOT was 2.5 (2–2.5) | p-value < 0.001 | ||
Median difference in subjective score of incontinence before and after HBOT was 0.5 (0–1) | p-value = 0.003 | ||
Median difference in subjective score of decreased stream before and after HBOT was 0 (0–1) | p-value = 0.14 | ||
The median difference in sum of all subjective scores before and after HBOT was 5 (5–6) | p-value < 0.001 | ||
Significant difference was reported between haematuria response and the time interval between the first episode of haematuria and HBOT | p-value < 0.05 |