Changes in Quality of Life After Lung Surgery in Old and Young Patients: Are They Similar?

A guide for managing patients with stage I NSCLC: deciding between lobectomy, segmentectomy, wedge, SBRT and ablation-part 2: systematic review of evidence regarding resection extent in generally healthy patients

Background

Clinical decision-making for patients with stage I lung cancer is complex. It involves multiple options (lobectomy, segmentectomy, wedge, stereotactic body radiotherapy, thermal ablation), weighing multiple outcomes (e.g., short-, intermediate-, long-term) and multiple aspects of each (e.g., magnitude of a difference, the degree of confidence in the evidence, and the applicability to the patient and setting at hand). A structure is needed to summarize the relevant evidence for an individual patient and to identify which outcomes have the greatest impact on the decision-making.

Methods

A PubMed systematic review from 2000-2021 of outcomes after lobectomy, segmentectomy and wedge resection in generally healthy patients is the focus of this paper. Evidence was abstracted from randomized trials and non-randomized comparisons with at least some adjustment for confounders. The analysis involved careful assessment, including characteristics of patients, settings, residual confounding etc. to expose degrees of uncertainty and applicability to individual patients. Evidence is summarized that provides an at-a-glance overall impression as well as the ability to delve into layers of details of the patients, settings and treatments involved.

Results

In healthy patients there is no short-term benefit to sublobar resection vs. lobectomy in randomized and non-randomized comparisons. A detriment in long-term outcomes is demonstrated by adjusted non-randomized comparisons, more marked for wedge than segmentectomy. Quality-of-life data is confounded by the use of video-assisted approaches; evidence suggests the approach has more impact than the resection extent. Differences in pulmonary function tests by resection extent are not clinically meaningful in healthy patients, especially for multi-segmentectomy vs. lobectomy. The margin distance is associated with the risk of recurrence.

Conclusions

A systematic, comprehensive summary of evidence regarding resection extent in healthy patients with attention to aspects of applicability, uncertainty and effect modifiers provides a foundation on which to build a framework for individualized clinical decision-making.

A guide for managing patients with stage I NSCLC: deciding between lobectomy, segmentectomy, wedge, SBRT and ablation-part 3: systematic review of evidence regarding surgery in compromised patients or specific tumors

Background

Clinical decision-making for patients with stage I lung cancer is complex. It involves multiple options [lobectomy, segmentectomy, wedge, stereotactic body radiotherapy (SBRT), thermal ablation], weighing multiple outcomes (e.g., short-, intermediate-, long-term) and multiple aspects of each (e.g., magnitude of a difference, the degree of confidence in the evidence, and the applicability to the patient and setting at hand). A structure is needed to summarize the relevant evidence for an individual patient and to identify which outcomes have the greatest impact on the decision-making.

Methods

A PubMed systematic review from 2000-2021 of outcomes after lobectomy, segmentectomy and wedge resection in older patients, patients with limited pulmonary reserve and favorable tumors is the focus of this paper. Evidence was abstracted from randomized trials and non-randomized comparisons (NRCs) with adjustment for confounders. The analysis involved careful assessment, including characteristics of patients, settings, residual confounding etc. to expose degrees of uncertainty and applicability to individual patients. Evidence is summarized that provides an at-a-glance overall impression as well as the ability to delve into layers of details of the patients, settings and treatments involved.

Results

In older patients, perioperative mortality is minimally altered by resection extent and only slightly affected by increasing age; sublobar resection may slightly decrease morbidity. Long-term outcomes are worse after lesser resection; the difference is slightly attenuated with increasing age. Reported short-term outcomes are quite acceptable in (selected) patients with severely limited pulmonary reserve, not clearly altered by resection extent but substantially improved by a minimally invasive approach. Quality-of-life (QOL) and impact on pulmonary function hasn't been well studied, but there appears to be little difference by resection extent in older or compromised patients. Patient selection is paramount but not well defined. Ground-glass and screen-detected tumors exhibit favorable long-term outcomes regardless of resection extent; however solid tumors <1 cm are not a reliably favorable group.

Conclusions

A systematic, comprehensive summary of evidence regarding resection extent in compromised patients and favorable tumors with attention to aspects of applicability, uncertainty and effect modifiers provides a foundation for a framework for individualized decision-making.

Patient features predicting long-term survival and health-related quality of life after radical surgery for non-small cell lung cancer

Background

This study presents a retrospective evaluation of patient, disease, and treatment features predicting long‐term survival and health‐related quality of life (HRQoL) among patients who underwent surgery for non‐small cell lung cancer (NSCLC).

Methods

Between January 2000 and June 2009, 586 patients underwent surgery at the Helsinki University Hospital. The 276 patients still alive in June 2011 received two validated quality of life questionnaires (QLQ): the generic 15D and the cancer‐specific EORTC QLQ‐C30 + QLQ‐LC13. We used binary and linear regression analysis modeling to identify patient, disease, and treatment characteristics that predicted survival and long‐term HRQoL.

Results

When taking into account patient, disease, and treatment characteristics, long‐term survival was quite predictable (69.5% correct), but not long‐term HRQoL (R² between 0.041 and 0.119). Advanced age at the time of surgery, male gender, comorbidity (measured with the Charlson comorbidity index), clinical and pathological stages II‐IV, and postoperative infectious complications predicted a lower survival rate. Features associated with poorer long‐term HRQoL (measured with the 15D) were comorbidity, postoperative complications, and the use of the video‐assisted thoracoscopic surgery (VATS) technique.

Conclusions

Long‐term HRQoL is only moderately predictable, while prediction of long‐term survival is more reliable. Lower HRQoL is associated with comorbidities, complications, use of the VATS technique, and reduced pulmonary function, while adjuvant therapy is associated with higher HRQoL.

Regaining familiarity with own body after treatment for operable lung cancer - a qualitative longitudinal exploration

Little is known about the experiences of operable lung cancer patients during treatment in a clinical setting based on fast-track surgery. The study aimed to explore (1) the embodied meaning of illness in patients with operable lung cancer during treatment to 4 months after surgery and (2) patterns of change over time that may affect the patients' daily lives. Twenty patients referred for lung cancer surgery were interviewed three times, corresponding to potential critical transition points following surgery: hospitalisation; hospital-to-home transition; and resumption of daily life activities. Data collection, analysis and interpretation followed a phenomenological hermeneutical approach inspired by Ricoeur and the theoretical framework was grounded in Merleau-Ponty's phenomenology of perception. The findings reveal the process patients went through in regaining familiarity with their own body after lung cancer treatment. Through the post-operative trajectory the patients' resumption of daily activities involved adjusting to a new awareness of everyday life, physical restrictions and their perception of themselves. The findings are expressed in four sub-themes: (1) perceptions of embodied alterations; (2) transformation of embodied structures in the transition from hospital to home was unexpectedly challenging; (3) embodied perceptions of the intersubjective world; and (4) transforming embodied disruptions into bodily awareness. Patients experienced a smooth treatment trajectory regarding physical consequences of illness and treatment which might be due to the fast-track surgery. Clinicians should be aware of patients' experiences of illness to facilitate patient reconstitution of own identity.

Optimal Preoperative Evaluation and Perioperative Care of the Geriatric Patient: A Surgeon's Perspective

The elderly preoperative patient benefits from an assessment that includes more than a routine physical examination and electrocardiogram. Such an assessment includes domains likely to affect the elderly: cognition, functionality, frailty, polypharmacy, nutrition, and social support. This fosters decisions based on functional age rather than chronologic age and on each patient as an individual. One such assessment is that promulgated by the American College of Surgeons National Surgery Quality Improvement Program/American Geriatrics Society Best Practice Guidelines. We should not miss any opportunity to improve results in this growing population of surgical patients.

Trajectories of Symptom Occurrence and Severity From Before Through Five Months After Lung Cancer Surgery

CONTEXT

Limited information is available about lung cancer patients' symptoms in the pre- and postoperative periods.

OBJECTIVES

Study purposes were to evaluate for changes in symptom occurrence and severity from the preoperative period to five months after surgery and to evaluate for predictors of the occurrence and trajectories of these symptoms.

METHODS

Patients completed the Memorial Symptom Assessment Scale before and at one and five months after surgery. Changes in the six most common physical symptoms and the most common psychological symptom were evaluated using multilevel growth mixture modeling. Age, gender, comorbidity, and receipt of adjuvant chemotherapy were included as covariates in the conditional models for symptom occurrence and severity.

RESULTS

The total number of symptoms increased significantly from the preoperative to the one month assessment. At five months, the number of symptoms was lower than at one month but significantly higher than at the preoperative assessment. The occurrence of five of the symptoms (i.e., pain, lack of energy, shortness of breath, feeling drowsy, and worrying) increased significantly from before through the first month after surgery and then decreased over time. Cough and difficulty sleeping persisted over the five months of the study. In general, the effect of the four covariates was to increase patients' overall symptom burden.

CONCLUSION

Changes in the occurrence and severity of these seven symptoms were variable. All seven symptoms occurred at relatively high rates and were of moderate severity. Findings can be used to identify patients who are at higher risk for more severe symptoms.

Minimally invasive lung surgery and postoperative quality of life

Quality of life (QOL) after medical interventions is paramount to the patient considering treatment recommendations. To understand QOL in thoracic surgery patients, one must examine the outcomes patients prioritize (preferences) from successful surgical therapy, overall functional status of thoracic surgery patients, the literature addressing QOL after thoracic surgery (TS) and the possible benefit of minimally invasive TS, and, finally, future directions of TS postoperative QOL research. The primary focus of this article is lung cancer surgery with mention of other thoracic disease such as empyema, pneumothorax, or emphysema, as well.

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.

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

OBJECTIVE

The aim of the study was to examine the long-term health-related quality of life following surgery for lung cancer.

METHODS

We performed a prospective population-based cohort study to explore health-related quality of life after lung surgery. We used a validated quality-of-life instrument (Short Form-36 (SF-36)) to gather information on health-related quality of life at baseline, 6 months, and 2 years after surgery. The main outcome measures were the SF-36 physical component summary (PCS) and mental component summary (MCS) scores.

RESULTS

Between 2006 and 2008, 249 patients were included. The response rate at 6 months was 85% and, at 2 years of follow-up, was 95%. The study population consisted of 166 patients who completed all three SF-36 questionnaires. The PCS score decreased from baseline to 6 months (47.4 vs 41.1; p < 0.001) and remained unchanged at the 2-year follow-up (41.1 vs 41.4). The MCS score increased from baseline to 6 months (40.5 vs 44.6; p = 0.001), with a further improvement at 2 years (44.6 vs 46.9; p = 0.005). At 2-year follow-up, both the PCS score and the MCS score of the study population were lower than that of an age- and gender-matched reference population (41.4 vs 44.0; p = 0.013 and 46.9 vs 50.6; p = 0.01).

CONCLUSIONS

We found that patients undergoing surgery for lung cancer had an early decrease in the physical aspect of health-related quality of life at 6 months after surgery, which was still present at 2 years of follow-up. A moderate clinically relevant improvement was noted in the mental aspect at 6 months and further improvement was reported at 2 years of follow-up.