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

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.

The esophageal remnant after gastric interposition

Gastric interposition is usually considered the reconstruction of choice following esophageal resection. However, a number of reports show that esophagectomy followed by a gastric transplant is associated with poor quality of life and significant reflux esophagitis in the esophageal remnant. The aim of this work is to review the factors affecting the mucosa of the esophageal remnant when using the stomach. A Medline was conducted. Additional references and search pathways were sourced from the references of reviewed articles. Reflux disease is considered an unavoidable consequence of esophageal resection followed by gastric interposition. Mucosal damage from acid and bile exposure in the esophageal remnant affects approximatively 50% of these patients. There is usually no correlation between symptoms and the presence of mucosal damage in the remaining esophagus. Endoscopy and endoscopic biopsies are the only reliable methods to document the status of the mucosa. When present, reflux esophagitis shows a progression from inflammation to erosions and to the development of columnar lined metaplasia. Esophageal and gastric function, gastric drainage operation, level of the anastomosis, route of reconstruction, and patients' position after the operation have all been shown to influence the severity and extent of damage in the esophageal remnant. Prevention and treatment of esophagitis in the remaining esophagus are discussed. When the stomach is used as a substitute to reconstruct the esophagus whether for malignant or benign conditions, an in vivo model of reflux diseases is created. Studies using this model may help clarify molecular and cellular events that lead to irreversible insult on the esophageal mucosa. Improvement to the reconstruction itself must be sought to favor better results with the gastric transplant.

No influence of surgical volume on patients' health-related quality of life after esophageal cancer resection

BACKGROUND

Studies on factors that can counteract the negative impact of esophagectomy on patients' health-related quality of life (HRQL) have been sparse. This study was undertaken to examine the question whether hospital or surgeon volume influences HRQL as evaluated 6 months after such surgery.

MATERIALS AND METHODS

A Swedish prospective, population-based cohort study of esophageal cancer patients treated surgically in 2001-2005 was conducted. All patients completed validated HRQL questionnaires, developed by EORTC, addressing general HRQL (QLQ-C30) and esophageal-specific symptoms (QLQ-OES18), 6 months postoperatively. Mean scores with 95% confidence intervals were calculated. Clinically relevant mean score differences (>/=10) between groups were further analyzed in a linear regression model, adjusted for several potential confounders.

RESULTS

Some 355 patients were included (80% of eligible). No clinically relevant differences were found between low-volume (0-9 operations/year) and high-volume hospitals (>9 operations/year) or between low-volume (0-6 operations/year) and high-volume surgeons (>6 operations/year). Stratified analyses for tumor location did not reveal any differences between hospital or surgeon volume groups. Moreover, no material differences were found between the four individual high-volume hospitals.

CONCLUSION

This study revealed no HRQL advantages of being treated at high-volume hospitals or by high-volume surgeons, as measured 6 months after esophageal cancer resection.