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

Minimally invasive oesophagectomy versus open surgery: is there an advantage?

BACKGROUND

Oesophageal resection is the main method of curative treatment for cancer of the oesophagus. Despite advances in surgical technology and postoperative care, the survival rate and prognosis of people undergoing oesophagectomy is still poor. The use of minimally invasive techniques in oesophageal surgery offers hope of reduced recovery time due to a reduction in surgical trauma. Although the first reports of thoracoscopy- and laparoscopy-assisted oesophagectomy emerged some 20 years ago, there is still no consensus that the outcomes are clearly superior to outcomes following conventional open surgery. Increasingly, some surgeons promote the use of minimally invasive techniques for oesophagectomy but questions remain over its safety and efficacy compared with open surgery.

METHODS

We conducted a systematic review of the literature to compare minimally invasive techniques for oesophagectomy to open surgery. The outcomes of interest for efficacy and safety included mortality, operative complications, recurrence, and quality of life.

RESULTS

There were 28 included comparative studies. No randomised controlled studies (RCTs) were available and therefore the data need to be interpreted with caution.

CONCLUSION

Recommendations for future research are discussed. We argue that it is difficult to conduct an RCT for this procedure due to ethical considerations and suggest ways that future nonrandomised studies could be improved.

Quality of life in pulmonary surgery: choosing, using, and developing assessment tools

There is mounting recognition that, to aid surgical decision making, treatment efficacy needs to be measured in a variety of ways, with health-related quality of life now widely regarded as an important outcome in pulmonary surgical populations. The aim of this review is to provide a comprehensive overview of the key issues to consider if an investigator wishes to incorporate health-related quality of life assessment into trials and studies of pulmonary surgery, drawing on recent studies of lung cancer surgery as an example.

Addressing patients' information needs: a first evaluation of a question prompt sheet in the pretreatment consultation for patients with esophageal cancer

This study aims to develop and pilot a question prompt sheet to assist esophageal cancer patients to obtain desired information in the consultation in which potentially curative esophagectomy is discussed. Whether a prompt sheet affected patients' question asking, the number and scope of topics discussed, the length of the consultation, and patients' satisfaction is investigated. Patients (n= 30) were randomized either to receive care as usual (control group) or to receive a prompt sheet (intervention group). All patients completed a baseline questionnaire, their consultations were audio-recorded and content-coded, and they received a structured telephone interview 2 days after the consultation to assess satisfaction. Patients provided with the prompt sheet marked a median of 19 questions. They asked significantly more questions as compared with patients in the control group (median of 12 vs. 8 questions). Questions mainly addressed treatment options and procedures. No differences were found with regard to consultation length and patient satisfaction. Our results suggest that providing patients with a simple, easy-to-implement tool such as a question prompt is appreciated and helps patients to ask more questions during the consultation without increasing the length of the consultation.

Postoperative information needs and communication barriers of esophageal cancer patients

OBJECTIVE

Given the poor prognosis of esophageal cancer and the impact of surgery on health-related quality of life (HRQL), addressing patients' postoperative information needs is important. This study aimed to examine (1) the content and type of patients' information needs and (2) patient perceived facilitators and barriers to patient participation.

METHODS

Interviews were conducted with 20 purposefully selected esophageal cancer patients. Open and structured questions were alternated. The transcribed interviews were analysed inductively and deductively, using MAXqda.

RESULTS

Patients' post-operative information needs concerned HRQL, medical care and prognosis, covering several sub-domains. Different types of needs were identified, e.g., requests for information about cause, course and self-management. Barriers to patient participation mostly reflected beliefs and skills, and could be categorized into agenda and communication barriers. Facilitators of patient participation reflected physician, patient and interaction characteristics, companion support and pre-visit preparation. Many patients saw merit in pre-visit preparation interventions; few endorsed skill-building interventions.

CONCLUSION

This study listed the postoperative information needs of esophageal cancer patients. Moreover, it gained insight into patient-perceived barriers and facilitators of patient participation.

PRACTICE IMPLICATIONS

The findings demonstrate what information physicians should have available and informs interventions to support patients in meeting their information needs.

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.

Road map to esophagectomy for nurses

Esophageal cancer, although considered uncommon in the United States, continues to exhibit increased incidence. Esophageal cancer now ranks seventh among cancers in mortality for men in the United States. Even as treatment continues to advance, the mortality rate remains high, with a 5-year survival rate less than 35%. Esophageal cancer typically is discovered in advanced stages, which reduces the treatment options. When disease is locally advanced, esophagectomy remains the standard for treatment. Surgery remains challenging and complicated. Multiple surgical approaches are available, with the choice determined by tumor location and stage of disease. Recovery is often fraught with complications-both physical and emotional. Nursing care revolves around complex care managing multiple body systems and providing effective education and emotional support for both patients and patients' families. Even after recovery, local recurrence and distant metastases are common. Early diagnosis, surgical advancement, and improvements in postoperative care continue to improve outcomes.

[Quality of life of patients with cancer of the oesophagus and stomach]

The study of the health related quality of life in patients with digestive tract cancer, and particularly in those with tumours of the oesophagus and stomach, provides useful information for selecting the most suitable therapeutic option. It may also be used to predict the impact of the disease and its possible treatments on the physical, emotional and social condition of the patient. Various sensitive and reliable tools have been developed over the past decades that are capable of measuring the quality of life of patients; the use of questionnaires has made it easier to exchange information between the patient and the doctor. The pre- and post-operative variations in the quality of life in patients with oesophageal-gastric cancer are of prognostic value on the outcome of the disease. For all these reasons, the health related quality of life is currently considered, along with disease free survival and absence of recurrences, one of the most important parameters in order to assess the impact on the patients of a particular oncological treatment. The aim of this article is to review the role of the health related quality of life assessment, as well as the various tools which are available to measure it in patients with oesophageal-gastric cancer.

Discrete-choice preference comparison between patients and doctors for the surgical management of oesophagogastric cancer

BACKGROUND

Establishing preferences for surgery is paramount to preoperative patient counselling. This study aimed to prioritize and compare preferences of patients and doctors towards surgery for oesophagogastric cancer, to aid the counselling process.

METHODS

A discrete-choice questionnaire containing hypothetical scenarios was designed to test patient preferences for six treatment attributes: mortality, morbidity, quality of life (QoL), cure rate, hospital type and surgeon's reputation. The survey was mailed to all patients who underwent oesophagogastric cancer resection from 2008 to 2009 at two teaching hospital sites. All doctors at these sites with previous experience in counselling patients for cancer surgery were also identified and presented with the survey. Results were analysed using a random-effects probit regression model. Spearman correlation was used to compare participants' implicit choices from the discrete-choice scenarios (their true preferences) with their explicit choices from the direct ranking of preferences (their perceived preferences).

RESULTS

Eighty-one patients and 90 doctors completed the survey. Some 15 per cent of patients and 31 per cent of doctors based their choices solely on QoL. In order of importance, patients based their implicit responses on QoL (β = 1.19), cure rate (β = 0.82), morbidity (β = - 0.70), surgeon's reputation (β = 0.60), mortality (β = - 0.57) and hospital type (β = 0.26). Doctors similarly indicated QoL (β = 1.14) and hospital type (β = 0.31) as highest and lowest preferences respectively, but placed far greater emphasis on mortality (β = - 0.80) than morbidity (β = - 0.35). Implicit and explicit preferences correlated only for morbidity and surgeon's reputation in the patient cohort.

CONCLUSION

Clinicians may better meet patients' expectations and facilitate informed decision-making if QoL, cure rate and morbidity are emphasized foremost. A similar study employing preoperative patients is warranted for further clarification of preferences.

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.

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.

Predictors of postoperative quality of life after esophagectomy for cancer

PURPOSE

To identify factors predictive of health-related quality of life (HRQL) 6 months after surgery for esophageal cancer.

PATIENTS AND METHODS

A Swedish nationwide population-based study of patients undergoing esophagectomy for cancer was undertaken between 2001 and 2005. Clinical details (sex, age, body mass index [BMI], comorbidity) and tumor details (histology, stage, and location) were prospectively recorded and validated. HRQL questionnaires (European Organisation for Research and Treatment of Cancer Quality of Life Questionnaires C30 and OES18) were used to assess HRQL 6 months postoperatively. HRQL outcome was categorized as good or poor by collapsing the four response categories. Logistic regression models adjusting for potential confounding factors were used to assess the association between preoperative patient and tumor characteristics and HRQL outcome 6 months after surgery.

RESULTS

A total of 355 patients (77% of eligible) responded to the HRQL questionnaires. Age, sex, and BMI showed no associations with HRQL 6 months after surgery, but patients with comorbidity, a more advanced tumor stage (III to IV), or a tumor located in the middle or upper esophagus had an increased risk of poor HRQL. Patients with adenocarcinoma had a lower risk of poor HRQL than patients with squamous cell carcinoma.

CONCLUSION

Knowledge of risk factors for poor postoperative HRQL may be relevant for clinical decision making. More research to see whether these factors are further predictive of poor HRQL in long-term survivors is needed.