Quality of life in patients with oesophageal cancer

Quality of life in patients with upper GI malignancies managed by a strategy of chemoradiotherapy alone versus surgery

BACKGROUND AND OBJECTIVES

Neoadjuvant chemoradiotherapy (nCRT) induces a pathological complete response (pCR) in 25-85% of oesophago-gastric cancer. As surgery entails morbidity and mortality risks and quality of life (QL) impairment, its avoidance in patients without residual disease is desirable. This study aimed to compare quality of life of patients with a cCR who chose surveillance with those who chose surgery.

METHODS

Four groups of patients were studied. Group 1(n = 31) were controls; Group 2 (n = 26) had chemoradiotherapy only; Group 3 (n = 31) had oesophagectomy after nCRT; Group 4 (n = 26) had gastrectomy alone. A 33-point novel questionnaire was administered at two 3 month time points. Participants were also interviewed with a validated questionnaire.

RESULTS

Mean(±sd) quality of life scores in cCR patients offered surveillance (28.9 ± 4.5) were superior to patients undergoing oesophagectomy (32.3 ± 58. p=0.042) or gastrectomy (33.19 ± 5.9, p=0.004). This result was replicated in the validated questionnaire (p=0.017). There was a trend towards increased reflux-related respiratory symptoms in the oesophagectomy group (7.3 ± 2.2 vs 6.5 ± 1.9; p=0.396) and towards early dumping (8.2 ± 1.4 vs 7.1 ± 1.; p=0.239) and vagotomy-related symptoms (1.82 ± 0.9 vs 1.4 ± 0.6; p=0.438) in the gastrectomy group.

CONCLUSIONS

Avoidance of surgery in cCR patients is rewarded with a superior quality of life to those undergoing surgery.

What surgeons tell patients and what patients want to know before major cancer surgery: a qualitative study

BACKGROUND

The information surgeons impart to patients and information patients want about surgery for cancer is important but rarely examined. This study explored information provided by surgeons and patient preferences for information in consultations in which surgery for oesophageal cancer surgery was discussed.

METHODS

Pre-operation consultations in which oesophagectomy was discussed were studied in three United Kingdom hospitals and patients were subsequently interviewed. Consultations and interviews were audio-recorded, transcribed in full and anonymized. Interviews elicited views about the information provided by surgeons and patients' preferences for information. Thematic analysis of consultation-interview pairs was used to investigate similarities and differences in the information provided by surgeons and desired by patients.

RESULTS

Fifty two audio-recordings from 31 patients and 7 surgeons were obtained (25 consultations and 27 patient interviews). Six consultations were not recorded because of equipment failure and four patients declined an interview. Surgeons all provided consistent, extensive information on technical operative details and in-hospital surgical risks. Consultations rarely included discussion of the longer-term outcomes of surgery. Whilst patients accepted that information about surgery and risks was necessary, they really wanted details about long-term issues including recovery, impact on quality of life and survival.

CONCLUSIONS

This study demonstrated a need for surgeons to provide information of importance to patients concerning the longer term outcomes of surgery. It is proposed that "core information sets" are developed, based on surgeons' and patients' views, to use as a minimum in consultations to initiate discussion and meet information needs prior to cancer surgery.

Patient-reported outcomes during and after definitive chemoradiotherapy for oesophageal cancer

BACKGROUND

Limited data describe patient-reported outcomes (PROs) of localised oesophageal cancer treated with definitive chemoradiotherapy(CRT). The phase 2/3 SCOPE-1 trial assessed the effectiveness of CRT±cetuximab. The trial for the first time provided an opportunity to describe PROs from a multi-centre group of patients treated with CRT that are presented here.

METHODS

Patients undergoing CRT±cetuximab within the SCOPE-1 trial (258 patients from 36 UK centres) completed generic-, disease- and treatment-specific health-related quality of life (HRQL) questionnaires (EORTC QLQ-C30, QLQ-OES18, Dermatology Life-Quality Index (DLQI)) at baseline and at 7, 13, 24, 52 and 104 weeks. Mean EORTC functional scale scores (>15 point change significant), DLQI scores (>4 point change significant) and proportions of patients (>15% significant) with 'minimal' or 'severe' symptoms are presented.

RESULTS

Questionnaire response rates were good. At baseline, EORTC functional scores were high (>75%) and few symptoms were reported except for severe problems with fatigue, insomnia and eating-related symptoms (e.g., appetite loss, dysphagia, dry mouth) in both groups(>15%). Functional aspects of health deteriorated and symptoms increased with treatment and by week 13 global quality of life, physical, role and social function significantly deteriorated and more problems with fatigue, dyspnoea, appetite loss and trouble with taste were reported. Recovery occurred by 6 months (except severe fatigue and insomnia in >15% of patients) and maintained at follow-up with no differences between groups.

CONCLUSIONS

CRT for localised oesophageal cancer has a significant detrimental impact on many aspects of HRQL; however, recovery is achieved by 6 months and maintained with the exception of persisting problems with severe fatigue and insomnia. The data suggest that the HRQL recovery after definitive CRT is quicker, and there is little lasting deficit compared with treatment including surgery. These data need to be compared with HRQL data from studies evaluating treatments including surgery for oesophageal cancer.

British Society of Gastroenterology guidelines on the diagnosis and management of Barrett's oesophagus

These guidelines provide a practical and evidence-based resource for the management of patients with Barrett's oesophagus and related early neoplasia. The Appraisal of Guidelines for Research and Evaluation (AGREE II) instrument was followed to provide a methodological strategy for the guideline development. A systematic review of the literature was performed for English language articles published up until December 2012 in order to address controversial issues in Barrett's oesophagus including definition, screening and diagnosis, surveillance, pathological grading for dysplasia, management of dysplasia, and early cancer including training requirements. The rigour and quality of the studies was evaluated using the SIGN checklist system. Recommendations on each topic were scored by each author using a five-tier system (A+, strong agreement, to D+, strongly disagree). Statements that failed to reach substantial agreement among authors, defined as >80% agreement (A or A+), were revisited and modified until substantial agreement (>80%) was reached. In formulating these guidelines, we took into consideration benefits and risks for the population and national health system, as well as patient perspectives. For the first time, we have suggested stratification of patients according to their estimated cancer risk based on clinical and histopathological criteria. In order to improve communication between clinicians, we recommend the use of minimum datasets for reporting endoscopic and pathological findings. We advocate endoscopic therapy for high-grade dysplasia and early cancer, which should be performed in high-volume centres. We hope that these guidelines will standardise and improve management for patients with Barrett's oesophagus and related neoplasia.

Quality of Life after Emergency Vs. Elective Esophagectomy with Cervical Reconstruction

Introduction:

Esophagectomy with reconstruction by collar anastomosis has an impact on the patients' quality of life (QOL). The aim of this study was to explore a potential difference in QOL between elective and emergency esophagectomy with collar reconstruction.

Patients and Methods:

Quality of life questionnaires were evaluated in 17 patients prior to esophagectomy, shortly after surgery, hospital discharge, and at least > 9 months after surgery using the EORTC QLQ C30 and EORTC OES 18 forms. In all patients reconstruction was performed by high collar anastomosis. Patients in group A received elective esophageal resection. In group B emergency esophagectomy was performed because of esophageal perforation for various reasons apart from cancer. In this group, delayed reconstruction was performed in a second operation 3–6 months after esophagectomy.

Results:

There was a temporary decrease of postoperative QOL in both groups, which returned to preoperative values in the follow-up except for physical functioning, which remained decreased in group A (p < 0,05). There were no persisting differences in QOL after elective and emergency esophagectomy in the follow-up.

Discussion:

Patients with elective and emergency esophagectomy and reconstruction by high collar anastomosis gained a good long-term QOL in our cohort of patients. This gives evidence that the observed QOL after elective resection of esophageal cancer is not only caused by a relief of cancer burden, but also due to a surgical procedure which is able to provide a good long-term QOL.

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.

Refining esophageal cancer staging after neoadjuvant therapy: importance of treatment response

OBJECTIVE

Accurate staging is vital for esophageal cancer management. The utility of the American Joint Committee on Cancer (AJCC) staging system 6th edition for esophageal cancer has been questioned for resected patients who receive neoadjuvant chemoradiotherapy (CRT). This study was undertaken to assess the AJCC staging system for patients with esophageal cancer that have received neoadjuvant CRT and to identify clinicopathological variables that predict survival.

METHODS

Review of a prospective esophageal cancer database was undertaken for patients that received neoadjuvant CRT and resection. Primary tumor response was defined as major (</=10% residual tumor cells) or minor (>10% residual tumor cells). Cox regression and concordance analyses were used to determine prognostic factors. Median follow-up was 61 months.

RESULTS

Of 131 patients with invasive cancer, there were 40/131 (31%) with squamous cell carcinoma (SCC) and 88/131 (65%) with adenocarcinoma. The procedure-related mortality rate was 3.8%. Median survival was 33 months. A major response was demonstrated by 79/131 (60%) patients. Survival analyses found that the AJCC 6th edition was unable to discriminate between stages 0, I, and IIa or stages IIb and III. Multivariate survival analyses found age, pretreatment tumor length >6 cm, positive lymph nodes, and a major tumor response were independent prognostic factors. These data were used to derive a new staging system that had improved discrimination of stage groups over the current AJCC system.

CONCLUSION

The current AJCC staging system for esophageal cancer is inadequate for patients that receive neoadjuvant CRT. Refinement of the AJCC staging system should include primary tumor response for patients receiving neoadjuvant CRT.

Palliative total pharyngo-laryngo-esophagectomy

OBJECTIVE

To evaluate the outcomes of total pharyngo-laryngo-esophagectomy (TPLE) as a palliative procedure for achieving oral intake without tube placement.

BACKGROUND

Patients with head and neck cancers require airway maintenance achieved by the placement of a tracheostomy tube and nutrition provided through a gastric fistula or a central vein, which may markedly decrease the quality of life (QOL) of the patients.

CASES

Two patients with cervical esophageal cancer are described. The first patient was a 69-year-old male with cervical esophageal cancer with vertebral invasion, for which complete resection was not possible. Following TPLE, oral intake was initiated on post-operative day 9 and was maintained for 138 days. The second patient was a 73-year-old male with recurrent cervical esophageal cancer and unresectable lymph node metastasis for which lymph node dissection was not applicable. Following TPLE, oral intake was initiated on post-operative day 7 and was maintained for 199 days. Both patients were satisfied with the outcome.

CONCLUSIONS

The QOL of the two patients was improved following the restoration of oral intake ability. Palliative TPLE may be appropriate for patients with advanced head and neck cancers.

The multidisciplinary team meeting improves staging accuracy and treatment selection for gastro-esophageal cancer

The object of this article is to assess current staging accuracies for individual modalities and to investigate the influence of the multidisciplinary team (MDT) on clinical staging accuracies and treatment selection for patients with gastro-esophageal cancer. Patients newly diagnosed with gastric or esophageal cancer and who were deemed suitable for surgical resection by the MDT were studied. Patients were staged with a combination of computerized tomography (CT), endoscopic ultrasound (EUS) and laparoscopic ultrasound (LUS). Additionally, the MDT determined an overall clinical stage for each patient after discussion at the MDT meeting. Treatments were selected according to this final clinical stage. Final histopathological staging (pTNM) was available for all patients and was used as the gold standard for determining staging accuracy. Suitability of treatment selection was assessed once final pTNM was available. One hundred and eighteen patients were studied. Endoscopic ultrasound was the most accurate individual staging modality for the loco-regional assessment of esophageal tumors (T stage accuracy 78%, N stage accuracy 70%). Laparoscopic ultrasound was the most accurate modality in T staging of gastric cancers (91%). The MDT stage was more accurate than each individual staging modality for T and N staging for both gastric and esophageal cancers (accuracy range: 88-89%) and was better for the assessment of nodal disease than each individual modality (CT P < 0.001, EUS P < 0.01, LUS P < 0.01). Overall staging accuracy as determined at the MDT meeting was increased and resulted in only 2/118 (2%) patients being under-treated. The MDT significantly improves staging accuracy for gastro-esophageal cancer and ensures that correct management decisions are made for the highest number of individual patients.

Inhibition of peroxisome proliferator-activated receptor gamma activity in esophageal carcinoma cells results in a drastic decrease of invasive properties

Esophageal cancer is difficult to treat because of its rapid progression, and more effective therapeutic approaches are needed. The PPARgamma is a nuclear receptor superfamily member that is expressed in many cancers. PPARgamma expression is a feature of esophageal cancer cell lines, and in the present investigation, the PPARgamma antagonists T0070907 and GW9662 could induce loss of invasion but could not induce growth reduction or apoptosis at low concentrations (< 10 mM). A high concentration of antagonists (50 microM) inhibited cell growth and induced apoptosis, but these effects did not explain our result at the low concentration. Morphological change, decreased expression of the cell signaling pathway and inhibition of cancer cell invasion were observed in the low concentration. This suggested that PPARgamma antagonists inhibited esophageal cancer cell invasion as well as cell adherence, most likely due to alteration in the FAK-MAPK pathway, and this was independent of apoptosis. These results suggested that PPARgamma plays an important role in cancer cell invasion and that it might be a novel target for therapy of esophageal cancer.

Quality of life in newly diagnosed cancer patients waiting for surgery is seriously impaired

BACKGROUND AND OBJECTIVES

Newly diagnosed cancer patients waiting for initial surgery experience a stressful time. Study objectives were (1) to examine the quality of life (QL) of these patients by comparing QL (a) between the four diagnostic groups included in this study, (b) to the QL of the general population, (2) to determine the factors that contribute most to patients' overall QL.

METHODS

One hundred ninety six patients with lung, periampullary, oesophageal and cervical cancer completed questionnaires on generic QL (SF-36), overall QL, cancer-site specific symptoms (EORTC-modules), anxiety (STAI), health expectations, demographics and comorbidity.

RESULTS

Between diagnostic groups no significant differences were found on generic QL. As compared to the general population, generic QL was impaired on all aspects except bodily pain. Using stepwise regression analysis, 46% of the variance in overall QL was explained with the SF-36 scales vitality (Beta = 0.43) and mental health (Beta = 0.23) being the most important predictors.

CONCLUSIONS

The QL of these patients is seriously impaired. In this stage, not cancer-site specific aspects but fatigue and emotions colour their lives. It is recommended to keep the waiting period brief. In addition, suggestions are offered by which physicians might help their patients in alleviating the distress.

Patients' experiences of living with oesophageal cancer

AIMS

The aim of this study is to describe patients' experiences of living with oesophageal cancer and how they seek information.

BACKGROUND

Oesophageal cancer is a devastating disease with poor prognosis. Nursing care for individuals with oesophageal cancer requires increased knowledge of how they experience illness and how it affects them.

METHOD

Data were collected by semi-structured, qualitative interviews with 13 participants. Content analysis was used to analyse data.

RESULTS

Four themes were identified: (i) Experiences of becoming a patient diagnosed with oesophageal cancer is distinguished by the participants' experiences of vague symptoms, of receiving the diagnosis and of existential concerns evoked by the illness. (ii) Experiences of undergoing investigations and treatment consist of the participants' experiences of extreme tiredness in relation to investigations and treatment. (iii) Experiences of intrusions in daily life is conceptualized by the participants' experiences of how the illness influenced their daily life. (iv) Managing a life-threatening illness consists of a variety of strategies, which the participants employed to manage their life-threatening illness.

CONCLUSIONS

The participants were unprepared of receiving a diagnosis of oesophageal cancer. Dysphagia, fatigue and uncertainty influenced the participants' everyday life. To manage the illness one of their strategies was seeking for information. The physicians were considered the main source of information, but family as well as friends with medical knowledge were also acknowledged as valuable sources.

RELEVANCE TO CLINICAL PRACTICE

Understanding patients' experiences of living with oesophageal cancer is important to improve nursing care. When caring for these patients, focus ought to be on the whole family. In nursing care, it is important to be aware of the effects of dysphagia and fatigue. Health-care professionals ought to organize meetings with fellow patients and recommend literature and websites that provide patients with high quality information.

Methodology for scientific evaluation of palliative surgery

Measuring the success of surgical palliation is not straightforward.To measure the benefits as well as limitations of surgical palliation,surgeons need outcome assessments other than the existing traditional measures of 30-day surgical morbidity and mortality and 5-year survival. This article delineates a scientific method of evaluating and measuring surgical palliation and shares techniques and pitfalls of assessment gained from prior experience.

Survival after oesophagectomy for cancer of the oesophagus

BACKGROUND

Formerly an inevitably fatal disease, oesophageal cancer today has predictable chances for cure.

METHODS

The recent literature and authors' own experiences in the surgical management of oesophageal cancer was reviewed to identify factors associated with improved survival after oesophagectomy.

RESULTS

Currently reported overall 5-year-survival rates are reaching 40% and more in patients who have had an oesophagectomy performed with curative intention. The reasons for improved survival after surgical resection are multifactorial in nature: decreased postoperative mortality and morbidity (due to improved patient selection, surgical technique and perioperative management), the use of tailored surgical strategies (adopted to the histological tumour type, tumour location, stage of disease and the individual patient's risk profile), and multimodality treatment in patients with locally advanced disease.

CONCLUSION

The prognosis of patients who have had oesophagectomy for oesophageal cancer has markedly improved during the past decades. With improved long-term survival after oesophagectomy, postoperative quality of life gains importance as an additional parameter of outcome after oesophageal cancer surgery.

Photodynamic therapy for Barrett's esophagus and high grade dysplasia: results of a patient satisfaction survey

There are few data available describing the experience of patients who have undergone photodynamic therapy with porfimer sodium for Barrett's esophagus. We describe the results of a satisfaction survey reported by 16 of 18 patients (11 men, 5 women; median age 75 years; median response at 27 months after treatment) treated with photodynamic therapy for Barrett's esophagus with high-grade dysplasia. Treatments were performed on an outpatient basis although two patients required clinic visits for intravenous fluids. Subjects reported their most significant post-treatment problem was odynophagia or dysphagia (75%), which was best treated with a hydrocodone bitartrate and acetaminophen elixir (75%). Cutaneous photosensitivity persisted for a median of six weeks; two patients had phototoxic reactions requiring clinic evaluation and treatment. All but two patients reported swallowing problems lasting a median of four weeks, and weight loss (median 6.8 kg). All patients indicated they would again choose photodynamic therapy if they were faced with a similar choice of endoscopic treatment versus surgery for Barrett's esophagus with high-grade dysplasia. These results indicate a generally high level of satisfaction in patients who have been treated with porfimer sodium photodynamic therapy for Barrett's esophagus with high-grade dysplasia.

Impact of surgical treatment on quality of life of patients with gastrointestinal tumors

Quality-of-life assessment is becoming an important concern even of surgeons. The new trend applies specifically to surgical oncology, where particular attention is now being paid to the outcome of surgical treatment. Gastrointestinal cancers are heterogeneous in their presentation and in treatment, but they share common aspects related to the surgical approach. A functional outcome is fundamental in all the operations performed for gastrointestinal cancers and many improvements have been made thanks to the increased rate of conservative approaches and the amelioration of the technology applied to surgery. The measurement of the surgical outcome and the methods to be applied is still undergoing extensive evaluation but the flourishing interest in the issues concerning quality of life all over the surgical community will rapidly lead to a better definition of goals and results.

Transhiatal vs extended transthoracic resection in oesophageal carcinoma: patients' utilities and treatment preferences

To assess patients' utilities for health state outcomes after transhiatal or transthoracic oesophagectomy for oesophageal cancer and to investigate the patients' treatment preferences for either procedure. The study group consisted of 48 patients who had undergone either transhiatal or transthoracic oesophagectomy. In an interview they were presented with eight possible health states following oesophagectomy. Visual Analogue Scale and standard gamble techniques were used to measure utilities. Treatment preference for either transhiatal or transthoracic oesophagectomy was assessed. Highest scores were found for the patients' own current health state (Visual Analogue Scale: 0.77; standard gamble: 0.97). Lowest scores were elicited for the health state "irresectable tumour" (Visual Analogue Scale: 0.13; standard gamble: 0.34). The Visual Analogue Scale method produced lower estimates (P<0.001) than the standard gamble method for all health states. Most patient characteristics and clinical factors did not correlate with the utilities. Ninety-five per cent of patients who underwent a transthoracic procedure and 52% of patients who underwent a transhiatal resection would prefer the transthoracic treatment. No significant associations between any patient characteristics or clinical characteristics and treatment preference were found. Utilities after transhiatal or transthoracic oesophagectomy were robust because they generally did not vary by patient or clinical characteristics. Overall, most patients preferred the transthoracic procedure.

Impact of intraoral soft-tissue reconstruction on the development of quality of life after ablative surgery in patients with oral cancer

The aim of this prospective study was to assess the impact of intraoral soft-tissue reconstruction on the development of quality of life after ablative surgery for oral cancer. A total of 107 patients were enrolled in the study during the period between 1997 and 1999. Quality of life was assessed by using the quality-of-life core questionnaire and the head and neck module of the European Organization for Research and Treatment of Cancer. The questionnaires were distributed to the patients preoperatively on the day of hospital admission and 3 months, 6 months, and 12 months postoperatively. A total of 53 patients filled in all questionnaires and were available for complete longitudinal analysis. The changes in the scores and the impact of defect size, location, and anatomy, the extent of mandibular resection, and the mode of soft-tissue reconstruction were tested longitudinally for statistical significance by using repeated-measures analysis of variance procedures. Of all parameters tested, the mode of soft-tissue reconstruction had the most profound impact on the development of quality of life after ablative surgery for oral cancer in that it was associated with statistically significant changes in the most domains or items associated with postoperative quality of life. In contrast to local flaps, revascularized soft-tissue repair with forearm flaps was associated with an intermittent deterioration of physical and functional scores but was followed by improvement until the end of the first year, and it even surpassed the preoperative baseline level in oral functional and social domains. In large-volume defects, which required repair by myocutaneous grafts, quality of life was not restored to the same extent, and physical, functional, and social domains remained significantly lower.