Health-related quality of life during neoadjuvant treatment and surgery for localized esophageal carcinoma

Neoadjuvant chemoradiotherapy for resectable esophageal cancer: an in-depth study of randomized controlled trials and literature review

Surgery following neoadjuvant chemoradiotherapy (NCRT) is a common multidisciplinary treatment for resectable esophageal cancer (EC). After analyzing 12 randomized controlled trials (RCTs), we discuss the key issues of surgery in the management of resectable EC. Along with chemoradiotherapy, NCRT is recommended for patients with squamous cell carcinoma (SCC) and adenocarcinoma (AC), and most chemotherapy regimens are based on cisplatin, fluorouracil (FU), or both (CF). However, taxane-based schedules or additional studies, together with newer chemotherapies, are warranted. In nine clinical trials, post-operative complications were similar without significant differences between two treatment groups. In-hospital mortality was significantly different in only 1 out of 10 trials. Half of the randomized trials that compare NCRT with surgery in EC demonstrate an increase in overall survival or disease-free survival. NCRT offers a great opportunity for margin negative resection, decreased disease stage, and improved loco-regional control. However, NCRT does not affect the quality of life when combined with esophagectomy. Future trials should focus on the identification of optimum regimens and selection of patients who are most likely to benefit from specific treatment options.

Developing core outcomes sets: methods for identifying and including patient-reported outcomes (PROs)

BACKGROUND

Synthesis of patient-reported outcome (PRO) data is hindered by the range of available PRO measures (PROMs) composed of multiple scales and single items with differing terminology and content. The use of core outcome sets, an agreed minimum set of outcomes to be measured and reported in all trials of a specific condition, may improve this issue but methods to select core PRO domains from the many available PROMs are lacking. This study examines existing PROMs and describes methods to identify health domains to inform the development of a core outcome set, illustrated with an example.

METHODS

Systematic literature searches identified validated PROMs from studies evaluating radical treatment for oesophageal cancer. PROM scale/single item names were recorded verbatim and the frequency of similar names/scales documented. PROM contents (scale components/single items) were examined for conceptual meaning by an expert clinician and methodologist and categorised into health domains. A patient advocate independently checked this categorisation.

RESULTS

Searches identified 21 generic and disease-specific PROMs containing 116 scales and 32 single items with 94 different verbatim names. Identical names for scales were repeatedly used (for example, 'physical function' in six different measures) and others were similar (overlapping face validity) although component items were not always comparable. Based on methodological, clinical and patient expertise, 606 individual items were categorised into 32 health domains.

CONCLUSION

This study outlines a methodology for identifying candidate PRO domains from existing PROMs to inform a core outcome set to use in clinical trials.

Imaging strategies in the management of oesophageal cancer: what's the role of MRI?

OBJECTIVES

To outline the current role and future potential of magnetic resonance imaging (MRI) in the management of oesophageal cancer regarding T-staging, N-staging, tumour delineation for radiotherapy (RT) and treatment response assessment.

METHODS

PubMed, Embase and the Cochrane library were searched identifying all articles related to the use of MRI in oesophageal cancer. Data regarding the value of MRI in the areas of interest were extracted in order to calculate sensitivity, specificity, predictive values and accuracy for group-related outcome measures.

RESULTS

Although historically poor, recent improvements in MRI protocols and techniques have resulted in better imaging quality and the valuable addition of functional information. In recent studies, similar or even better results have been achieved using optimised MRI compared with other imaging strategies for T- and N-staging. No studies clearly report on the role of MRI in oesophageal tumour delineation and real-time guidance for RT so far. Recent pilot studies showed that functional MRI might be capable of predicting pathological response to treatment and patient prognosis.

CONCLUSIONS

In the near future MRI has the potential to bring improvement in staging, tumour delineation and real-time guidance for RT and assessment of treatment response, thereby complementing the limitations of currently used imaging strategies.

KEY POINTS

• MRI's role in oesophageal cancer has been somewhat limited to date. • However MRI's ability to depict oesophageal cancer is continuously improving. • Optimising TN-staging, radiotherapy planning and response assessment ultimately improves individualised cancer care. • MRI potentially complements the limitations of other imaging strategies regarding these points.

Assessment and comparison of recovery after open and minimally invasive esophagectomy for cancer: an exploratory study in two centers

BACKGROUND

Minimally invasive esophagectomy (MIE) may lead to early restoration of health-related quality of life, but few prospective comparative studies have been performed. This exploratory study compared recovery between totally minimally invasive esophagectomy (MIE), laparoscopically assisted esophagectomy (LAE) and open surgery (OE).

METHODS

A prospective study in 2 specialist centers recruited consecutive patients undergoing OE, LAE, or MIE for high-grade dysplasia or cancer. Patients completed validated questionnaires, the Multi-Dimensional Fatigue Inventory (MFI-20), modified Katz Scale, and modified Lawton and Brody Scale (assessing activities of daily living) before and 6 weeks and 3 and 6 months after surgery.

RESULTS

A total of 97 patients (26 women; median age 64 years) were scheduled for surgery that was abandoned in 11 due to occult low-volume metastatic disease. In the remaining 86 (OE = 19, LAE = 31, and MIE = 36), there were 4 in-hospital deaths (4 %), and 54 postoperative complications (OE = 12, LAE = 19, and MIE = 23). Overall questionnaire compliance was high (77 %) and baseline scores similar in all groups, although clinical differences between groups were observed with earlier tumors and more squamous cell cancers selected for MIE. Following surgery fatigue levels increased dramatically and activity levels reduced in all groups. These gradually recovered to baseline following MIE and LAE within 6 months, but the ability to perform activities of daily living and most parameters of fatigue had not returned to baseline levels in the OE group.

CONCLUSIONS

This exploratory prospective nonrandomized study of recovery after different types of surgery for esophageal cancer showed possible small benefits to MIE. A much larger study is needed to confirm these findings.

The role of multi-disciplinary teams in decision-making for patients with recurrent malignant disease

BACKGROUND

It is mandatory in many countries for decisions for all new patients with cancer to be made within multi-disciplinary teams (MDTs). Whether patients with disease recurrence should also routinely be discussed by the MDT is unknown.

AIM

This study investigated the role of an upper gastro intestinal (UGI) MDT in decision-making for patients with disease recurrence.

DESIGN

A retrospective review of prospectively kept MDT records (2010 to 2011) was performed identifying patients discussed with recurrence of oesophagogastric cancer. Information was recorded about: i) why an MDT referral was made, ii) who made the referral and iii) the final MDT recommendation. Implementation of the MDT recommendation was also examined.

PARTICIPANTS

All patients discussed with recurrence of cancer at a central UGI cancer MDT were included.

RESULTS

During the study 54 MDT meetings included discussions regarding 304 new patients and 29 with disease recurrence. Referrals to the MDT for patients with recurrence came from outpatient clinics (n=19, 65.5%) or following emergency admission (n=10). Most referrals were made by the surgical team (n=25, 86.2%). MDT recommendations were best supportive care (n=11, 37.9%), palliative chemotherapy (n=9, 31.0%), stent (n=5, 17.2%), palliative radiotherapy (n=3, 10.3%) and further surgery (n=1, 3.4%), with 25 (86.2%) of these implemented.

CONCLUSION

UGI MDTs focus on new referrals and only a small proportion of patients with recurrent disease are re-discussed. Many patients go on to receive further treatments. Whether such patients are optimally managed within the standard MDT is uncertain, however, and warrants further consideration.

Quality of life after three kinds of esophagectomy for cancer

AIM: To evaluate quality of life (QOL) following Ivor Lewis, left transthoracic, and combined thoracoscopic/laparoscopic esophagectomy in patients with esophageal cancer.

METHODS: Ninety patients with esophageal cancer were assigned to Ivor Lewis (n = 30), combined thoracoscopic/laparoscopic (n = 30), and left transthoracic (n = 30) esophagectomy groups. The QOL-core 30 questionnaire and the supplemental QOL-esophageal module 18 questionnaire for patients with esophageal cancer, both developed by the European Organization for Research and Treatment of Cancer, were used to evaluate patients’ QOL from 1 wk before to 24 wk after surgery.

RESULTS: A total of 324 questionnaires were collected from 90 patients; 36 postoperative questionnaires were not completed because patients could not be contacted for follow-up visits. QOL declined markedly in all patients at 1 wk postoperatively: preoperative and 1-wk postoperative global QOL scores in the Ivor Lewis, combined thoracoscopic/laparoscopic, and left transthoracic groups were 80.8 ± 9.3 vs 32.0 ± 16.1 (P < 0.001), 81.1 ± 9.0 vs 53.3 ± 11.5 (P < 0.001), and 83.6 ± 11.2 vs 46.4 ± 11.3 (P < 0.001), respectively. Thereafter, QOL recovered gradually in all patients. Patients who underwent Ivor Lewis esophagectomy showed the most pronounced decline in QOL; global scores were lower in this group than in the combined thoracoscopic/laparoscopic (P < 0.001) and left transthoracic (P < 0.001) groups at 1 wk postoperatively and was not restored to the preoperative level at 24 wk postoperatively. QOL declined least in patients undergoing combined thoracoscopic/laparoscopic esophagectomy, and most indices had recovered to preoperative levels at 24 wk postoperatively. In the Ivor Lewis and combined thoracoscopic/laparoscopic groups, pain and physical function scores were 78.9 ± 18.5 vs 57.8 ± 19.9 (P < 0.001) and 59.3 ± 16.1 vs 70.2 ± 19.2 (P = 0.02), respectively, at 1 wk postoperatively and 26.1 ± 28.6 vs 9.5 ± 15.6 (P = 0.007) and 88.4 ± 10.5 vs 95.8 ± 7.3 (P = 0.003), respectively, at 24 wk postoperatively. Scores in the left transthoracic esophagectomy group fell between those of the other two groups.

CONCLUSION: Compared with Ivor Lewis and left transthoracic esophagectomies, combined thoracoscopic/laparoscopic esophagectomy enables higher postoperative QOL, making it a preferable surgical approach for esophageal cancer.

Multimodal treatment of esophageal cancer

BACKGROUND

The treatment of localized esophageal cancer has been debated controversially over the past decades. Neoadjuvant treatment was used empirically, but evidence was limited due to the lack of high-quality confirmatory studies. Meanwhile, data have become much clearer due to recently published well-conducted randomized controlled trials and meta-analyses.

METHODS

Neoadjuvant and perioperative platinum fluoropyrimidine-based combination chemotherapy has now an established role in the treatment of stage II and stage III esophageal adenocarcinoma and cancer of the esophago-gastric junction. Neoadjuvant chemoradiation is now the standard of care for treating stage II and stage III esophageal squamous cell cancer and can also be considered for treating esophageal adenocarcinoma.

RESULTS

Patients with esophageal squamous cell cancer treated with definitive chemoradiation achieve comparable long-term survival compared with surgery. Short-term mortality is less with chemoradiation alone, but local tumor control is significantly better with surgery.

CONCLUSION

This expert review article outlines current data and literature and delineates recommendable treatment guidelines for localized esophageal cancer.

Health-related quality of life after Ivor Lewis esophagectomy

PURPOSE

Transthoracic Ivor Lewis esophagectomy is a surgical standard therapy for esophageal carcinoma. The aim of this study was to assess health-related quality of life (HRQL) in mid- and long-term survivors.

METHODS

Patients with cancer-free survival of at least 12 months after esophageal resection for cancer were identified from a prospectively maintained database. EORTC questionnaires were sent out to assess health-related general (QLQ-C30) and esophageal cancer-specific (QLQ-OES18) quality of life (QOL). A numeric score was calculated in each conceptual area and compared with reference data.

RESULTS

One hundred forty-seven patients completed the self-rated questionnaires. They were 121 men and 26 women with a mean age of 63.4 (21-83) years; median FU was 39 (12-139) months. Global health status, functional scales, and symptom scores were significantly reduced compared with healthy reference populations. Also, there was no significant impact of tumor histology, neoadjuvant treatment, minimally invasive approach, or duration of follow-up on HRQL. However, more than half of the patients reported a HRQL similar to that of the healthy reference population.

CONCLUSIONS

Despite the major psychosocial and physiological impacts of the disease, more than 50 % of mid- and long-term survivors of the Ivor Lewis procedure for esophageal cancer have a HRQL similar to that of the healthy reference population.

Comparison of quality of life in patients undergoing transhiatal esophagectomy with or without chemotherapy

BACKGROUND/AIM

To compare the quality of life (QOL) in patients undergoing transhiatal esophagectomy (THE) with or without chemotherapy, who were admitted to the Post Graduate Institute of Medical Education and Research, Chandigarh and enrolled in the study, from July 2004 to October 2005.

PATIENTS AND METHODS

Thirty patients of esophageal carcinoma by purposive sampling were randomized into two groups i.e., patients undergoing THE after chemotherapy and patients undergoing THE without chemotherapy. Two QOL questionnaires, one generic i.e., EORTC-QLQ C-30 (European Organization for Research and Treatment of Cancer) and other esophageal cancer-specific i.e., EORTC OES-18 were utilized to assess the QOL.

RESULT

Physical functional scales were better in patients, who received neoadjuvant chemotherapy. The role and social aspects of functional scales deteriorated after completion of treatment in both groups. This was primarily due to the effect of surgery. However, they were better from an emotional and cognitive point of value after surgery and radiotherapy. Fourteen out of 30 patients experienced vomiting and diarrhea due to radiotherapy.

CONCLUSION

THE in esophageal carcinoma improves global health scales and majority of symptom scales in all patients. QOL improvement in general was better in patients who were administered neoadjuvant chemotherapy along with surgery.

Influence of major postoperative complications on health-related quality of life among long-term survivors of esophageal cancer surgery

PURPOSE

To evaluate the effect of major postoperative complications on health-related quality of life (HRQL) in 5-year survivors of esophageal cancer surgery.

PATIENTS AND METHODS

This study was based on the Swedish Esophageal and Cardia Cancer register with almost complete nationwide coverage and data on esophageal cancer surgery collected prospectively between 2001 and 2005. Patients who were alive 5 years after surgery were eligible. HRQL was assessed longitudinally until 5 years after surgery by using the validated European Organisation for Research and Treatment of Cancer (EORTC) Quality of Life Questionnaire C30 and OES18. Linear mixed models were used to assess the mean score difference (MD) with 95% CIs of each aspect of HRQL in patients with or without major postoperative complications. Adjustment was made for several potential confounders.

RESULTS

Of 153 patients who survived 5 years, 141 patients (92%) answered the 5-year HRQL questionnaires. Of these individuals, 46 patients (33%) sustained a major postoperative complication. Dyspnea (MD, 15; 95% CI, 6 to 23), fatigue (MD, 13; 95% CI, 5 to 20), and eating restrictions (MD, 10; 95% CI, 2 to 17) were clinically and statistically significantly deteriorated throughout the follow-up in patients with major postoperative complications compared with patients without major complications. Although problems with choking declined to levels comparable with patients without major postoperative complications, sleep difficulties and gastroesophageal reflux progressively worsened during follow-up.

CONCLUSION

The occurrence of postoperative complications exerts a long-lasting negative effect on HRQL in patients who survive 5 years after esophagectomy for cancer.

Quality of life after esophagectomy for cancer

Esophageal cancer is an aggressive and physically and emotionally devastating disease. It has one of the poorest survival rates among all malignant tumors, mainly due to late symptom presentation and early metastatic dissemination. Cure is possible through extensive surgery, typically followed by a long recovery period, affecting general well-being, as well as basic aspects of life, such as eating, drinking and socializing. Health-related quality of life (HRQL) is a multidimensional concept assessing symptoms and functions related to a disease or its treatment from the patient's perspective. HRQL is a fundamental part of treatment in surgical oncology, particularly in esophageal cancer. This review assesses the scientific data regarding some HRQL aspects after esophageal cancer surgery, for example, postoperative recovery time, determinants of postoperative HRQL and long-term HRQL.

Randomized controlled trial of laparoscopic gastric ischemic conditioning prior to minimally invasive esophagectomy, the LOGIC trial

INTRODUCTION

Minimally invasive esophagectomy (MIE) is a viable alternative to open resection for the management of esophagogastric cancer. However, the technique may relate to a higher incidence of ischemia-related gastric conduit complications. Laparoscopic ischemic conditioning (LIC) by ligating the left gastric vessels 2 weeks before MIE may have a protective role, possibly through an improvement of conduit perfusion. This project was designed to evaluate whether LIC influenced ultimate conduit perfusion.

METHODS

A randomized controlled trial was designed to compare MIE with LIC (L) against MIE without (N). The project began in May 2009 and was offered to consecutive patients with the objective of recruiting 22 in each arm. Sample size calculations were based on data from previous clinical series. The main outcome measure was perfusion recorded by validated laser Doppler fluximetry, at the fundus (F) and greater curve (G); performed at routine staging laparoscopy and every stage of an MIE. A perfusion coefficient measured as ratio at stage of MIE over baseline was used for statistical analysis.

RESULTS

Sixteen patients were recruited before an interim analysis of the trial data. At staging laparoscopy perfusion at F was higher than at G (p = 0.016). In the L cohort, an apparent rise in perfusion at G is observed post intervention (p = 0.176). At MIE, baseline perfusion is comparable for both arms; however, a significant drop is observed at both locations once the stomach is mobilized and exteriorized (p = 0.001). Once delivered at the neck, perfusion coefficient is approximately 38% of baseline levels. However, there was no discernible difference between the L (38.3 ± 12) and N (37.7 ± 16.8) cohorts (p = 0.798).

CONCLUSIONS

LIC does not translate into an improved perfusion of the gastric conduit tip. The benefits reported from published clinical series suggest that the resistance of the conduit to ischemia occurs through alternative possibly microcellular mechanisms.

Systematic review of health-related quality of life after esophagectomy for esophageal cancer

This study is aimed to assess the long-term health-related quality of life (HRQL) of patients after esophagectomy for esophageal cancer in comparison with es-tablished norms, and to evaluate changes in HRQL during the different stages of follow-up after esophageal resection. A systematic review was performed by searching medical databases (Medline, Embase and the Cochrane Library) for potentially relevant studies that appeared between January 1975 and March 2011. Studies were included if they addressed the question of HRQL after esophageal resection for esophageal cancer. Two researchers independently performed the study selection, data extraction and analysis processes. Twenty-one observational studies were included with a total of 1282 (12-355) patients. Five studies were performed with short form-36 (SF-36) and 16 with European Organization for Research and Treatment of Cancer (EORTC) QLQ C30 (14 of them also utilized the disease-specific OES18 or its previous version OES24). The analysis of long-term generic HRQL with SF-36 showed pooled scores for physical, role and social function after esophagectomy similar to United States norms, but lower pooled scores for physical function, vitality and general health perception. The analysis of HRQL conducted using the Global EORTC C30 global scale during a 6-mo follow-up showed that global scale and physical function were better at the baseline. The symptom scales indicated worsened fatigue, dyspnea and diarrhea 6 mo after esophagectomy. In contrast, however, emotional function had significantly improved after 6 mo. In conclusion, short- and long-term HRQL is deeply affected after esophagectomy for cancer. The impairment of physical function may be a long-term consequence of esophagectomy involving either the respiratory system or the alimentary tract. The short- and long-term improvement in the emotional function of patients who have undergone successful operations may be attributed to the impression that they have survived a near-death experience.

Systematic review: quality of life after treatment for upper gastrointestinal cancer

PURPOSE OF REVIEW

The aim of this systematic review is to scrutinize and summarize the design, conduct and reporting standards of articles recently published describing health-related quality of life (HRQL) outcomes of treatment of upper gastrointestinal cancer.

RECENT FINDINGS

Some 2312 abstracts were published between January and July 2009 and initial elimination of papers reduced this number to 22 articles. Of these, 17 were judged to have robust HRQL methodology, but a further seven were excluded due to a high risk of bias in the study design. Ten articles (four randomized trials) were finally included in the review. Studies in curative treatments for oesophagogastric cancer show that surgery and chemoradiation therapy has a major short-term detrimental effect on HRQL, but recovery occurs within 6 months in long-term survivors but those not achieving a survival benefit report very poor HRQL. In advanced oesophageal cancer, 18 mm self-expandable metal stents and nonstent therapies lead to better short-term HRQL scores than nonexpandable stents and are the recommended standard of care. A small survival advantage and improved HRQL is conferred by adjuvant and palliative gemcitabine chemotherapy in patients with pancreatic cancer.

SUMMARY

This review identified few well-designed studies that also included a robust assessment of HRQL. High-quality trials with reliable HRQL methods are required for outcomes to inform health policy and clinical decision-making.

Patient-reported outcomes after neoadjuvant chemoradiotherapy for rectal cancer: a multicenter prospective observational study

OBJECTIVE

To prospectively describe patient-reported outcomes (PROs) after preoperative chemoradiotherapy (pCRT) for rectal cancer.

BACKGROUND

Little evidence is available on PROs after pCRT for rectal cancer.

PATIENTS AND METHODS

Patients with rectal cancer, candidates to receive pCRT, were enrolled in a multicenter prospective observational trial. Health-related quality of life was assessed using the European Organisation for Research and Treatment of Cancer (EORTC) QLQ-C30 and its colorectal cancer module (QLQ-CR38), and fecal incontinence and bowel function were evaluated using the fecal incontinence score questionnaire and a set of ad hoc questions. Questionnaires were filled out before CRT (t₀), 2 to 3 weeks after completion of CRT (t₁), and at 6 (t₂) and 12 months (t₃) after surgery. Primary analysis of selected scales included: global quality of life, physical functioning, social functioning, fatigue, body image, future prospective, and gender-related sexual problems.

RESULTS

Of 149 eligible patients, questionnaires were completed in 100%, 95%, 88% and 77% of cases at t0, t₁, t₂, and t₃, respectively. At t₃, 78% of patients reported stool fractionation and 72% sensation of incomplete defecation. Only 14% of patients had optimal continence. Physical/social functioning, fatigue, and body image showed a decrease just after pCRT and returned to baseline levels at 1 year after treatment. Global quality of life was stable over time. Male sexual problems were greatly impaired throughout the study period (P < 0.001) with major clinically meaningful changes between baseline and 1 year after treatment.

CONCLUSIONS

These findings add to the body of evidence available regarding pCRT and help clinicians to make more informed treatment decisions.

Health-related quality of life in long-term survivors after high-dose chemoradiotherapy followed by surgery in esophageal cancer

Curative treatment of esophageal cancer with definitive or preoperative high-dose chemoradiotherapy inflicts a major strain on the patients with potentially severe physical, emotional, and social consequences. The aim of this study was to assess various aspects of quality of life and fatigue in long-term survivors following such a treatment. Patients undergoing a potentially curative treatment between 1996 and 2007, and still alive (n= 41) completed quality of life questionnaires of the European Organization for Research and Treatment of Cancer core questionnaire (QLQ-C30) and esophageal cancer module (QLQ-OES18). Twenty patients were treated by surgery alone, and 21 patients were scheduled for high-dose chemoradiotherapy followed by surgery. Five of those patients did not undergo planned surgery. Preoperative chemoradiotherapy consisted of three courses of chemotherapy, cisplatin 100 mg/m(2) and 5-fluorouracil 5000 mg/m(2) in each course and concomitant radiotherapy of a median dose 66 Gy. Quality of life in esophageal cancer patients receiving high-dose chemoradiotherapy was compared with that for esophageal cancer patients who received only surgery, head and neck cancer patients, laryngectomized patients, and a random sample of the general Norwegian population. Esophageal cancer patients treated by high-dose chemoradiotherapy had significantly worse global quality of life as reflected by almost all functional scales and higher fatigue compared with esophageal cancer patients who received surgery alone, head and neck cancer patients, and the general Norwegian population. There were no significant differences in quality of life between the esophageal cancer patients receiving high-dose chemoradiotherapy and the laryngectomy patients. Further, the esophageal cancer patients receiving high-dose chemoradiotherapy had higher intensity of other symptoms like general pain, insomnia, nausea/vomiting, diarrhea, and constipation compared with the esophageal cancer patients who received surgery alone, head and neck cancer patients, and the general Norwegian population. High-dose chemoradiotherapy with cisplatin and 5-fluorouracil had a considerable negative long-term effect on global quality of life in patients with resectable esophageal cancer. Fatigue was a prominent long-lasting symptom in these patients.

Health-related quality of life in long-term esophageal cancer survivors after potentially curative treatment

OBJECTIVE

Clinical outcomes have been investigated extensively in studies of esophageal cancer treatment. Less is known about long-term health-related quality of life outcomes. The aim of this study was to assess a range of health-related quality of life outcomes in patients with esophageal cancer treated with potentially curative intent at least 1 year earlier.

METHODS

Between January 1995 and December 2007, 163 consecutive patients with cancer of the esophagus underwent a potentially curative treatment. All patients with a minimal follow-up of 1 year and without tumor recurrence were eligible. Questionnaires included the European Organization for Research and Treatment of Cancer core questionnaire (QLQ-C30), the European Organization for Research and Treatment of Cancer esophageal cancer-specific questionnaire (QLQ-OES18), and additional questions concerning survivorship issues.

RESULTS

Thirty-seven patients met the inclusion criteria, of whom 36 completed the questionnaires. Twenty-one patients had received neoadjuvant therapy followed by surgery, 9 patients had undergone surgery only, and 6 patients had chemoradiation only. Median survival was 54 (range, 16-162) months. In general, patients reported better health-related quality of life than a reference sample of patients with esophageal cancer, but somewhat compromised health-related quality of life compared with a reference sample of individuals from the general population. Although some symptoms continued to persist, patients' overall evaluation on their treatment, employment status and finances, body weight and image, and survivorship issues was positive.

CONCLUSIONS

Patients who survive 1 year or more after potentially curative treatment for esophageal cancer can lead satisfactory lives. The results of this study can be used when informing patients with esophageal cancer about the long-term effects of treatment.

Health-related quality of life after minimally invasive oesophagectomy

BACKGROUND

Open oesophagectomy has a detrimental impact on health-related quality of life (HRQL), with recovery taking up to a year. Minimally invasive oesophagectomy (MIO) may enable a more rapid recovery of HRQL.

METHODS

Clinical outcomes from consecutive patients undergoing MIO for cancer were recorded between April 2005 and April 2007. Patients completed validated questionnaires, European Organization for Research and Treatment of Cancer QLQ-C30 and QLQ-OES18, before surgery and at 6 weeks, 3, 6 and 12 months after surgery.

RESULTS

MIO for cancer or high-grade dysplasia was planned in 62 patients, but abandoned in four owing to occult metastatic disease. Resection was completed in the remaining 58, two having partial conversion to open surgery. There was one in-hospital death and 29 patients developed complications. At 1 year, 52 of 58 patients were alive. Questionnaire response rates were high at each time point (overall compliance 84 per cent). Six weeks after MIO, patients reported deterioration in functional aspects of HRQL and more symptoms than at baseline. However, most improved by 3 months and had returned to baseline levels by 6 months. These levels were maintained 1 year after surgery, with 85 per cent of patients recovering in more than 50 per cent of the HRQL domains.

CONCLUSION

MIO leads to a rapid restoration of HRQL.

Health-related quality of life and survival in the 2 years after surgery for gastric cancer

BACKGROUND

This prospective study examined health-related quality of life (HRQL) and survival in patients with potentially curable gastric cancer.

METHODS

Consecutive patients (n=58) selected for curative surgery completed a validated questionnaire (EORTC QLQ-C30) and site-specific module (QLQ-STO22) before surgery and regularly for 2 years afterwards. Changes of 10 or more points on a 0-100 scale were considered clinically significant.

RESULTS

Some 30 patients were alive after 2 years (52%). In the first 3 months after surgery, HRQL was significantly reduced across all dimensions except emotional and cognitive functioning (mean reduction of 10 or more points). Functional aspects of HRQL recovered by 6 months in patients who subsequently were alive at 2 years, although at least a third of patients experienced specific symptoms, even 6 months after surgery, especially diarrhoea. For those dying within 2 years, some postoperative functional HRQL recovery occurred, but many symptoms were common.

CONCLUSIONS

Potentially curative gastrectomy for cancer has a detrimental impact on HRQL that mostly recovers in patients surviving some 2 years. Patients who die within 2 years may experience limited postoperative recovery. It is recommended that patients receive HRQL information about the outcomes of surgery for gastric cancer.

Prevalence and outcome of esophagogastric anastomotic leak after esophagectomy in a UK regional cancer network

The aim of this study was to determine the contemporary prevalence, outcome, and survival after esophagogastric anastomotic leakage (EGAL) following esophagectomy by a regional upper gastrointestinal cancer network and to investigate etiological factors. Two hundred forty consecutive patients underwent esophagectomy over a 10-year period (median age 61 [31-79] years, 147 transthoracic and 93 transhiatal esophagectomy, 105 neoadjuvant chemotherapy, 49 chemoradiotherapy). The primary outcome measures were the development of EGAL and survival. Twenty patients developed EGAL (8.3%, 15 managed conservatively, 5 reoperation). Overall operative mortality was 2% (5 patients in total, 1 after EGAL). Median, 1 and 2-year survival was 22 months, 73% and 50%, in patients after EGAL, compared with 31 months, 80% and 56%, in patients who did not suffer EGAL (P= 0.314). On multivariate analysis, low body mass indices (hazard ratio [HR] 0.29, 95% confidence interval [CI] 0.11-0.79, P= 0.016), individual surgeon (HR 1.21, 95% CI 1.02-1.43, P= 0.02), and neoadjuvant chemotherapy (HR 3.28, 95% CI 1.16-9.22, P= 0.024) were significantly associated with the development of EGAL. EGAL following esophagectomy remained common, but associated mortality was less common than reported in earlier Western series and long-term survival was unaffected.

Ischemic conditioning shows a time-dependant influence on the fate of the gastric conduit after minimally invasive esophagectomy

BACKGROUND

Minimally invasive esophagectomy (MIO) is now established as a valid alternative to open surgery for the management of esophagogastric cancers. However, a high incidence of ischemia-related gastric conduit failure (ICF) is observed, which is detrimental to any potential benefits of this approach.

METHODS

Since April 2004, MIO has been the procedure of choice for esophagogastric resection in the authors' unit. Data relating to the surgical technique were collected, with a focus on ischemic conditioning by laparoscopic ligation of the left gastric artery (LIC) 2 weeks or 5 days before resection.

RESULTS

A total of 97 patients underwent a planned MIO. Four in-patient deaths (4.1%) occurred, none of which were conduit related, and overall, 20 patients experienced ICF (20.6%). In four patients, ICF was recognized and dealt with at the initial surgery. The remaining 16 patients experienced this complication postoperatively, with 9 (9.3%) of them requiring further surgery. Of the 97 patients, 55 did not undergo ischemic conditioning, and conduit failure was observed in 11 (20%). Thirty-five patients had LIC at 2 weeks, and 2 (5.7%) experienced ICF. All seven patients (100%) who had LIC at 5 days experienced ICF. Timing of ischemic conditioning (p < 0.0001) had a definite impact on the conduit failure rate, and the benefit of ischemic conditioning at 2 weeks compared with no conditioning neared significance (p = 0.07).

CONCLUSIONS

Ischemic failure of the gastric conduit significantly impairs recovery after MIO. Ischemic conditioning 2 weeks before surgery may reduce this complication and allow the benefits of this approach to be realized.

Stage-for-stage comparison of definitive chemoradiotherapy, surgery alone and neoadjuvant chemotherapy for oesophageal carcinoma

BACKGROUND

Definitive chemoradiotherapy (dCRT) has been proposed as an alternative therapy for selected patients with oesophageal cancer. The aim of this study was to determine the outcomes of dCRT, surgery alone, and neoadjuvant chemotherapy followed by surgery (CS) in patients with oesophageal cancer.

METHODS

Consecutive patients diagnosed with oesophageal cancer and managed by a multidisciplinary team were staged by computed tomography and endoluminal ultrasonography. Those deemed unsuitable for surgery on the grounds of performance status, bulky local disease or personal choice received dCRT. The primary outcome measure was overall survival measured from date of diagnosis.

RESULTS

Of 417 patients, 173 received dCRT, 126 underwent surgery alone and 118 received CS. The incidence of grade III/IV toxicity after dCRT and CS was 39.3 and 60.2 per cent respectively. Operative morbidity rates were 42.9 and 44.4 per cent after surgery alone and CS respectively. Thirty-day mortality rates were zero, 7.9 and 0.8 per cent after dCRT, surgery alone and CS respectively. Overall 2-year survival rates were 44.3, 56.2 and 42.4 per cent (P = 0.422).

CONCLUSION

These findings support the need for a randomized trial of dCRT versus CS for resectable oesophageal cancer.

Long-term weight change after oesophageal cancer surgery

BACKGROUND

Malnutrition is common after oesophageal cancer surgery. This study investigated weight changes and the risk of malnutrition among long-term survivors.

METHODS

A nationwide cohort study was conducted in Sweden in 2001-2004, with follow-up to 2008. Weight was assessed before oesophagectomy, after 6 months and at 3 years. Logistic regression was performed with adjustment for confounders. Odds ratios (ORs) for postoperative weight loss of at least 15 per cent were estimated.

RESULTS

Some 203 patients survived at least 3 years after oesophagectomy. Continuous weight loss occurred for up to 3 years. Women and men had a similar risk of malnutrition after 3 years (OR 0.85 (95 per cent confidence interval 0.24 to 2.98)). In overweight patients (preoperative body mass index at least 25 kg/m(2)) the risk of malnutrition was increased almost fivefold at 6 months (OR 4.90 (2.27 to 10.59)) and 3 years (OR 4.60 (1.80 to 11.78)). There was no difference in weight loss at 6 months between survivors and those who died between 6 months and 3 years after surgery (OR 1.11 (0.64 to 1.94)).

CONCLUSION

Weight loss can be long lasting after oesophagectomy; overweight patients are at particularly increased risk of malnutrition.

Re-organisation of oesophago-gastric cancer care in England: progress and remaining challenges

Background

Oesophago-gastric cancer services in England have been extensively reorganised since 2001 to deliver a centralised, specialist-led service. Our aim was to assess how well the National Health Service (NHS) in England met organisational standards for oesophago-gastric cancer care.

Methods

Questionnaires that asked about the provision of staging investigations, curative and palliative treatments and key personnel were sent in September 2007 to the lead clinician for oesophago-gastric cancer at all 30 cancer networks and 156 NHS acute trusts in England.

Results

Responses were received from all networks and 81% of NHS trusts. All networks provided essential staging investigations and a range of endoscopic palliative therapies. Only 16 of the 30 cancer networks discussed all patients at the specialist multi-disciplinary team meeting and 11 networks had not fully centralised curative surgery. There was also variation between NHS trusts in the integration of the palliative care team, the availability of nurse specialists and the use of dieticians to provide nutritional support.

Conclusion

There has been considerable progress in reforming oesophago-gastric cancer services but the process of reorganisation is still incomplete and regional differences in service provision exist that may lead to variation in patient outcomes.

Is a change in patient-reported dysphagia after induction chemotherapy in locally advanced esophageal cancer a predictive factor for pathological response to neoadjuvant chemoradiation?

GOALS OF WORK

In patients with locally advanced esophageal cancer, only those responding to the treatment ultimately benefit from preoperative chemoradiation. We investigated whether changes in subjective dysphagia or eating restrictions after two cycles of induction chemotherapy can predict histopathological tumor response observed after chemoradiation. In addition, we examined general long-term quality of life (QoL) and, in particular, eating restrictions after esophagectomy.

MATERIALS AND METHODS

Patients with resectable, locally advanced squamous cell- or adenocarcinoma of the esophagus were treated with two cycles of chemotherapy followed by chemoradiation and surgery. They were asked to complete the EORTC oesophageal-specific QoL module (EORTC QLQ-OES24), and linear analogue self-assessment QoL indicators, before and during neoadjuvant therapy and quarterly until 1 year postoperatively. A median change of at least eight points was considered as clinically meaningful.

MAIN RESULTS

Clinically meaningful improvements in the median scores for dysphagia and eating restrictions were found during induction chemotherapy. These improvements were not associated with a histopathological response observed after chemoradiation, but enhanced treatment compliance. Postoperatively, dysphagia scores remained low at 1 year, while eating restrictions persisted more frequently in patients with extended transthoracic resection compared to those with limited transhiatal resection.

CONCLUSIONS

The improvement of dysphagia and eating restrictions after induction chemotherapy did not predict tumor response observed after chemoradiation. One year after esophagectomy, dysphagia was a minor problem, and global QoL was rather good. Eating restrictions persisted depending on the surgical technique used.

Risk factors for malnutrition after oesophageal and cardia cancer surgery

Background

Oesophageal cancer surgery is often followed by malnutrition, but the factors causing weight loss are unknown. The aim of this population-based study was to identify such risk factors.

Methods

Data were collected from a nationwide Swedish organization for research on surgery for oesophageal cancer. A total of 340 patients (75·9 per cent of those eligible) responded to a study-specific questionnaire concerning height and weight, just before and 6 months after surgery. Factors influencing malnutrition, defined as loss of body mass index of at least 15 per cent 6 months after operation, were identified by logistic regression.

Results

Neoadjuvant therapy (received by 10·6 per cent of all patients) and female sex were associated with at least a twofold increased risk of weight loss (odds ratio (OR) 2·41 (95 per cent confidence interval 1·01 to 5·77) and 2·14 (1·07 to 4·28) respectively), whereas preoperative weight loss was associated with a decreased risk (OR 0·13 (0·03 to 0·65)). Age, tumour stage and location, type of oesophageal substitute, suture technique and postoperative complications did not influence the risk.

Conclusion

Neoadjuvant therapy and female sex appear to be associated with an increased risk of malnutrition after oesophageal cancer surgery.

Long-term health-related quality of life following surgery for oesophageal cancer

BACKGROUND

The aim of the study was to assess health-related quality of life (HRQL) in patients with surgically cured oesophageal cancer.

METHODS

A Swedish nationwide cohort of patients undergoing oesophagectomy for cancer between April 2001 and January 2004 was studied prospectively, and compared with a Swedish age- and sex-adjusted reference population. Validated European Organisation for Research and Treatment of Cancer quality of life questionnaires were used to assess HRQL at 6 months and 3 years after surgery. A mean score difference of 10 or more between groups was considered clinically relevant and tested further for statistical significance.

RESULTS

Of 358 patients, 117 (32.7 per cent) survived for at least 3 years. Of these, 87 patients (74.4 per cent) responded to the questionnaires. Six months after surgery, most aspects of HRQL were substantially worse than in the reference population with no improvement at 3 years. Patients alive at 3 years reported significantly poorer role and social function, and significantly more problems with fatigue, diarrhoea, appetite loss, nausea and vomiting, than in the reference population.

CONCLUSION

HRQL in long-term survivors after oesophagectomy does not improve between 6 months and 3 years after surgery, and is worse than that in a comparable reference population.

The role of health-related quality of life outcomes in clinical decision making in surgery for esophageal cancer: a systematic review

BACKGROUND

Esophagectomy for cancer offers a chance of cure but is associated with morbidity, at least a temporary reduction in health-related quality of life (HRQL), and a 5-year survival of approximately 30%. This research evaluated how and whether HRQL outcomes contribute to surgical decision making.

METHODS

A systematic review identified randomized trials and longitudinal and cross-sectional studies that assessed HRQL after esophagectomy with multidimensional validated questionnaires. Articles were independently evaluated by two reviewers, and the value of HRQL in clinical decision making was categorized in three ways: (1) the assessment of the quality of HRQL methodology according to predefined criteria; (2) the influence of HRQL outcomes on treatment recommendations and/or informed consent; and (3) the HRQL after esophagectomy for cancer in methodologically robust studies.

RESULTS

Eighteen publications were identified, of which 16 (89%) were categorized as having robust HRQL design. Of these studies, 3 concluded that HRQL influenced treatment recommendations and 11 (including the former 3) informed patient consent. The remaining five papers were well designed, but the authors did not use HRQL to influence treatment recommendations or informed consent. After esophagectomy, patients report major deterioration in most aspects of HRQL with slow recovery.

CONCLUSION

HRQL outcomes are relevant to surgical decision making. Methods to communicate HRQL outcomes to patients are required to inform consent and clinical practice.

Role of PET/PET CT in the staging and restaging of thoracic oesophageal cancer and gastro-oesophageal cancer: a literature review

BACKGROUND

Current evidence for the use of FDG PET/PET-CT in staging thoracic oesophageal and GOJ cancer is reviewed.

METHODS

PubMed, Medline, Embase (1988-November 2006) and the Cochrane database identified studies in which FDG PET and PET CT were used for the assessment of thoracic and GOJ cancer.

RESULTS

Conventional assessment remains the mainstay for evaluating the primary site. EUS is used for assessing the primary site, but when EUS is incomplete or not tolerated FDG PET CT is invaluable. The major of advantage of FDG PET CT lies in the ability to detect metastatic disease beyond the celiac axis. There is growing evidence to show that FDG PET CT is useful for assessment of treatment response. FDG PET CT will also detect other occult primary cancers.

CONCLUSIONS

The contribution of FDG PET CT to the investigation of patients with primary thoracic oesophageal and GOJ cancer has resulted in improved staging, so providing the ability to optimise treatment.

Population-based study of surgical factors in relation to health-related quality of life after oesophageal cancer resection

BACKGROUND

Oesophagectomy for cancer has a negative impact on health-related quality of life (HRQL), but factors influencing postoperative HRQL have been sparsely studied. This study explored how selected surgical factors affected HRQL 6 months after operation.

METHODS

This population-based study was based on a Swedish network of physicians with almost complete nationwide coverage and data on oesophageal cancer surgery collected prospectively between 2001 and 2005. Patients completed validated HRQL questionnaires 6 months after operation. Mean scores with 95 per cent confidence intervals were calculated and clinically relevant differences between groups were analysed in a linear regression model, adjusted for potential confounders.

RESULTS

Some 355 patients were included in the analysis (participation rate 79.6 per cent). Extensive surgery, as indicated by a transthoracic approach, more extensive lymphadenectomy, wider resection margins and a longer duration of operation, was not associated with worse HRQL measures than less extensive operations. Dysphagia was similar in patients who had handsewn and stapled anastomoses. Technical surgical complications had significant deleterious effects on several aspects of HRQL.

CONCLUSION

This study provides no evidence to suggest that less extensive surgery for oesophageal cancer should be recommended from the perspective of HRQL. It is essential, however, that attention be paid to minimizing technical surgical complications.

Oxford experience with neoadjuvant chemotherapy and surgical resection for esophageal adenocarcinomas and squamous cell tumors

The Medical Research Council trial for oesophageal cancer (OEO2) trial demonstrated a clear survival benefit from neoadjuvant chemotherapy in resectable esophageal carcinoma. Since February 2000 it has been our practice to offer this chemotherapy regime to patients with T2 and T3 or T1N1 tumors. We analyzed prospectively collected data of patients who received neoadjuvant chemotherapy prior to esophageal resection under the care of a single surgeon. Complications of treatment and overall outcomes were evaluated. A total of 194 patients had cisplatin and 5-fluorouracil prior to esophageal resection. Six patients (5.7%) had progressive disease and were inoperable (discovered in four at surgery). During chemotherapy one patient died and one perforated (operated immediately). Complications including severe neutropenia, coronary artery spasm, renal impairment and pulmonary edema led to the premature cessation of chemotherapy in 12 patients (6.2%). A total of 182 patients with a median age of 63 (range 30-80), 41 squamous and 141 adenocarcinomas underwent surgery. Operations were 91 left thoracoabdominal (50%), 45 radical transhiatal (25%), 40 Ivor-Lewis (22%) and six stage three (3%), and 78.6% had microscopically complete (R0) resections. Median survival was 28 months with 77.3% surviving for 1 year and 57.7% for 2 year. In hospital mortality was 5.5% and anastomotic leak rate 7.7%. A radical surgical approach to the primary tumor in combination with OEO2 neoadjuvant chemotherapy has led to a high R0 resection rate and good survival with acceptable morbidity and mortality.

Quality of life during neoadjuvant treatment and after surgery for resectable esophageal carcinoma

PURPOSE

Because of the trade-off between the potentially negative quality-of-life (QoL) effects and uncertain favorable survival effect of neoadjuvant chemoradiotherapy (CRT) in patients with resectable esophageal cancer, we assessed heath-related QoL (HRQoL) for up to 1 year postoperatively in these patients treated with preoperative CRT with a non-platinum-based outpatient regimen followed by esophagectomy.

METHODS AND MATERIALS

Patients undergoing neoadjuvant paclitaxel and carboplatin therapy concurrent with radiotherapy followed by surgery completed standardized HRQoL questionnaires before and after CRT and at regular times up to 1 year postoperatively. We analyzed differences in generic Qol core questionnaire [QLQ-C30] and condition-specific (esophageal site-specific [OES-18]) HRQoL scores over time by using a linear mixed-effects model.

RESULTS

Mean scores of most HRQoL scales deteriorated significantly during neoadjuvant CRT. The largest deterioration was observed for physical and role-functioning scales. All except two symptom scores worsened significantly. Postoperatively, most mean HRQoL scores improved until recovery to baseline level. Speed of improvement varied. Average taste score returned to baseline 3 months postoperatively, whereas it took 1 year for the average role-functioning score to restore. The emotional-functioning score showed a different pattern; it was worst at baseline and increased over time during CRT and postoperatively. Dysphagia and pain scores worsened considerably during CRT, restored to baseline 3 months postoperatively, and were even significantly better 1 year postoperatively.

CONCLUSIONS

Preoperative CRT with paclitaxel and carboplatin for patients with resectable esophageal cancer had a considerable temporary negative effect on most aspects of HRQoL. Nonetheless, all HRQoL scores were restored or even improved 1 year postoperatively.

Impact of obesity on outcomes in the management of localized adenocarcinoma of the esophagus and esophagogastric junction

OBJECTIVE

Obesity trends in the Western world parallel the increased incidence of adenocarcinoma of the esophagus and esophagogastric junction. The implications of obesity on standard outcomes in the management of localized adenocarcinoma, particularly operative risks, have not been systematically addressed.

METHODS

This retrospective analysis of prospectively collected data included 150 consecutive patients (36 [24%] obese [body mass index > 30] and 114 nonobese), of whom 43 were normal weight (body mass index 20-25) and 71 were overweight (body mass index 25-30). Eighty-one patients underwent multimodal therapy. The primary end points were in-hospital mortality and morbidity, and median and overall survivals.

RESULTS

Thirty of 36 obese patients (84%) had a body mass index from 30 to 35. Compared with those of the nonobese cohort, obese patients had significantly increased respiratory complications (P = .037), perioperative blood transfusions (P = .021), anastomotic leaks (P = .009), and length of stay (P = .001), but no difference in mortality (P = .582) or major respiratory complications (P = .171). Median and overall survivals were equivalent (P = .348) in both groups.

CONCLUSIONS

Obesity was associated with increased respiratory complications and anastomotic leak rates but not with major respiratory complications, mortality, or survival. These outcomes suggest that the added risks of obesity on standard outcomes in esophageal cancer surgery are modest and should not independently have a significant impact on risk assessment in esophageal cancer management.

Health-related quality of life among patients cured by surgery for esophageal cancer

BACKGROUND

Little is known regarding the long-term, health-related quality of life (HRQL) of survivors of esophagectomy for cancer.

METHODS

Consecutive patients completed the validated European Organization for Research and Treatment of Cancer general quality-of life-questionnaire (QLQ-C30) and the esophageal-specific module (QLQ-OES18) before surgery and regularly thereafter for at least 3 years. Mean scores with 95% confidence intervals were calculated. The Student t test for paired data was used to determine differences between baseline and 3-year HRQL scores in which scores differed by >or=5 points.

RESULTS

Of 90 patients who underwent surgery, 47 patients (52%) survived for >or=3 years. In this group, most aspects of HRQL recovered to preoperative levels by the 3-year assessment, except that scores for physical function, breathlessness, diarrhea, and reflux were significantly worse than at baseline (P < .01). However, patients reported significantly better emotional function 3 years after surgery than before treatment (P = .0008).

CONCLUSIONS

Even after 3 years, patients who underwent esophagectomy suffered persistent problems with physical function and specific symptoms. These findings may be used to inform patients of the long-term consequences of surgery.

Esophagectomy--it's not just about mortality anymore: standardized perioperative clinical pathways improve outcomes in patients with esophageal cancer

BACKGROUND

Esophageal resection (ER) remains the standard therapy for early esophageal cancer; however, because of concerns regarding high levels of morbidity and mortality reported in analyses of national databases, many patients are relegated to less effective endoscopic or chemotherapeutic approaches.

METHODS

All patients undergoing esophagectomy by a single surgeon for cancer or high-grade dysplasia between 05/91-05/06 were prospectively entered into an IRB-approved database. All aspects of work-up and treatment were guided by an evolving standardized perioperative clinical pathway.

RESULTS

Three hundred forty consecutive patients, mean age of 64 (33-90), underwent ER for Barrett's esophagus (17) or invasive cancer stages I-87, II-133, III-94, IV-9. One hundred thirty-nine (41%) had neoadjuvant therapy. Sixty-three percent were American Society of Anesthesiologists class III or IV, and five different operative approaches were used. Patient were managed intraoperatively with a "fluid restriction" protocol. Mean intraoperative blood loss was 230 cc. 99.5% of patients were extubated immediately, and mean ICU and hospital stays were 2.25 (1-30) and 11.5 (6-49) days, respectively. Postoperative analgesia was managed with patient-controlled epidural analgesia in 98.5%, and 86% were mobilized on day 1 after surgery. Complications occurred in 153 patients (45%), most commonly atrial dysrhythmia (13%), and postoperative delirium (11%). Anastomotic leaks occurred in 13 patients (3.8%). Mortality occurred in one patient (0.3%). No significant differences were seen in length of stay, operative time, blood loss, or complications in patients receiving neoadjuvant therapy. For stages I, II, and III, patients between 1998-2004 Kaplan-Meier 5-year cumulative survival was 92.4, 57.1, and 34.5%, respectively.

CONCLUSIONS

Surgical treatment of esophageal cancer can be done with moderate morbidity and very low mortality, and the expectation of improved levels of survival, especially in early-stage patients. Standardized perioperative clinical pathways can provide the infrastructure for the treatment of these patients and should include increased efforts to minimize blood loss and transfusions, improve postoperative pain control and extubation rates, and facilitate early mobilization and discharge. ER, as sole therapy or in combination with radiation/chemotherapy, should remain the standard of care in patients with early and locoregional esophageal cancer.

Health-related quality-of-life assessment in gastrointestinal cancer: are results relevant for clinical practice?

PURPOSE OF REVIEW

Health-related quality-of-life studies are now recognized as critical to understand the burden of disease and treatments on patients' well being. Significant advances have been recently achieved in gastrointestinal cancers, including the development and clinical use of new robust quality-of-life instruments. We review recent literature to evaluate whether quality-of-life assessment contributes to optimal patient information and helps treatment choices.

RECENT FINDINGS

Treatments of gastrointestinal cancers have changed in the last few years with increasing use of multimodal therapies and advances in surgical techniques, especially for low-lying rectal cancers. Concurrent to the development of sphincter-saving procedures, however, the long-term consequences of a permanent stoma on quality of life have been debated. Results of new palliative treatments should also be considered looking at preservation or improvement of quality of life and not only prolongation of life.

SUMMARY

Gastrointestinal malignancies impact strongly on patient quality of life due to the aggressiveness of the treatments. Short-term negative effects of surgery and specific deficits in survivors were recently described in gastrointestinal cancers. Baseline quality-of-life data predict length of survival in hepatocarcinoma and metastatic colorectal cancer. Generally, quality-of-life results help to fully inform the patients of the advantages or disadvantages of therapeutic options, including adjuvant and palliative treatments.

Health-related quality of life among patients with adenocarcinoma of the gastro-oesophageal junction treated by gastrectomy or oesophagectomy

Background

Tumours of the gastro-oesophageal junction may be resected by total gastrectomy (TG) or transthoracic oesophagectomy (TTO). This study compared health-related quality of life (HRQL) following these procedures.

Methods

Prospective clinical and HRQL data (European Organization for Research and Treatment of Cancer QLQ-C30) were collected from 63 consecutive patients (20 TG and 43 TTO) before and 6 months after surgery for Siewert type I–III gastro-oesophageal tumours.

Results

Questionnaire response rates exceeded 90 per cent. Patients were similar with respect to disease stage, treatment-related mortality and survival, but those selected for TTO were younger with less co-morbidity than those undergoing TG. These differences were reflected in baseline HRQL scores, which were better in patients selected for TTO. Six months after surgery, however, HRQL showed a greater deterioration after TTO than after TG in terms of role and social function, global quality of life and fatigue. Symptom scores for pain and diarrhoea increased in both groups.

Conclusion

TTO had a greater negative impact on HRQL than TG for tumours of the gastro-oesophageal junction.

Quality of life during potentially curative treatment for locally advanced oesophageal cancer

Background

Combination chemoradiotherapy with or without surgery are internationally applied alternative strategies for potential cure of oesophageal cancer. This study compared health-related quality of life (HRQL) between patients selected for chemoradiation and those who had combination treatment including oesophagectomy.

Methods

Patients with stage II or III oesophageal cancer completed HRQL assessments at baseline, at the worst expected HRQL time point and at expected recovery. HRQL was compared between groups using linear regression, adjusting for age, sex, performance status, tumour stage and type, and baseline HRQL.

Results

Some 132 patients began treatment, of whom 51 had chemoradiotherapy and 81 combination treatment including surgery. Patients selected for chemoradiotherapy were older, more likely to have squamous cell cancer and reported poorer HRQL than those selected for surgery. At the worst expected time point after treatment, both groups reported multiple symptoms and poor function, but surgery was associated with a greater reduction in HRQL from baseline than chemoradiotherapy. Recovery of HRQL was achieved within 6 months after chemoradiotherapy, but complete recovery had not occurred 6 months after surgery and there was persistent significant deterioration in some aspects.

Conclusion

The negative treatment-related impact of chemoradiation on short-term HRQL is less than that experienced with combination treatment including surgery. Patients preferring early recovery should consider definitive chemoradiation.

Quality of life in patients with oesophageal and gastric cancer: an overview

An accurate assessment of health-related quality of life (QoL) in patients with oesophageal or gastric cancer (OGC) is essential to inform clinical decisions by providing insights into patients' experiences of the impact of the disease and its treatments on physical, social and emotional health. Robust QoL questionnaires have been developed and validated in the past decade to measure the QoL of OGC patients. Baseline QoL variables are also prognostic for survival in patients with oesophageal cancer or metastatic gastric cancer. This article reviews the impact of surgery and reconstructive techniques, as well as of adjuvant and palliative treatments on the QoL of patients with OGC.

Prospective evaluation of quality of life in patients with localized oesophageal cancer treated by multimodality therapy or surgery alone

BACKGROUND

Health-related quality of life (HRQL) outcomes are important in assessing new approaches to the treatment of cancer. Neoadjuvant therapy is being used increasingly before surgery in patients with localized oesophageal cancer. This prospective non-randomized study evaluated HRQL in patients treated by preoperative chemotherapy and radiation therapy followed by surgery (multimodal therapy) or by surgery alone.

METHODS

Data from European Organization for Research and Treatment of Cancer quality of life questionnaires QLQ-30 and QLQ-OES24 were collected prospectively. Questionnaires were completed at diagnosis, after chemoradiotherapy where applicable, and at 3, 6 and 12 months after surgery.

RESULTS

The study included 202 consecutive patients with oesophageal cancer considered suitable for curative (R0) resection at the time of staging. Eighty-seven patients received chemotherapy combined with external-beam radiotherapy before surgery. At baseline, 75 (86 percent) of 87 patients in the multimodal group completed questionnaires, compared with 72 (62.6 percent) of 115 in the surgery-alone group. There were no significant differences in baseline global HRQL scores between groups. Preoperative chemoradiotherapy significantly reduced physical (P=0.004) and role (P=0.007) functioning before surgery, despite a significant (P=0.043) improvement in the dysphagia score. Oesophageal resection had a negative impact on global, functional and symptom HRQL scores at 3 months in both groups. Most variables had recovered by 6 months in the two groups, but at 12 months physical and role functioning remained impaired in the surgery-alone group, and social functioning and financial worries in the multimodal group.

CONCLUSION

Although the multimodal regimen had a negative impact on HRQL before surgery, postoperative quality of life in patients who had multimodal therapy was similar to that in those who had surgery alone.

Percutaneous endoscopic gastrostomy risks rendering the gastric conduit unusable for esophagectomy

Surgical treatment for cancer of the esophagus most often involves replacement of the esophagus with a gastric conduit. This gastric tube relies upon the continuity of the gastroepiploic artery for its blood supply. This case report involves a patient whose gastroepiploic artery became thrombosed by a percutaneous endoscopic gastrostomy, rendering his gastric conduit unusable.