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

Different gastric tubes in esophageal reconstruction during esophagectomy

Esophagectomy is currently the mainstay of treatment for resectable esophageal carcinoma. Gastric grafts are the first substitutes in esophageal reconstruction. According to the different tailoring methods applied to the stomach, gastric grafts can be classified as whole stomach, subtotal stomach and gastric tube. Gastric-tube placement has been proven to be the preferred method, with advantages in terms of postoperative complications and long-term survival. In recent years, several novel methods involving special-shaped gastric tubes have been proposed, which have further decreased the incidence of perioperative complications. This article will review the progress and clinical application status of different types of gastric grafts from the perspectives of preparation methods, studies of anatomy and perioperative outcomes, existing problems and future outlook.

Recovery of Patient-reported Quality of Life After Esophagectomy

BACKGROUND

Esophagectomy is an important, but potentially morbid, operation used to treat benign and malignant conditions that may significantly impact patient quality of life (QOL). Patient-reported outcomes (PROs) are measures of QOL that come directly from patient self-report. This study characterizes patterns of change and recovery in PROs in the first year after esophagectomy.

METHODS

Longitudinal QOL scores measuring physical function, pain, and dyspnea were obtained from esophagectomy patients during all clinic visits. PRO scores were obtained using the National Institutes of Health-sponsored Patient-Reported Outcomes Measurement Information System from April 2018 to February 2021. Mean PRO scores over 100 days after surgery were compared with baseline PRO scores using mixed-effects modeling with compound symmetry correlational structure.

RESULTS

One hundred three patients with PRO results were identified. Reasons for esophagectomy were malignancy (87.4%), achalasia (5.8%), stricture (5.8%), and dysplasia (1.0%). When comparing mean PRO scores at visits ≤ 50 days after surgery with preoperative PRO scores, physical function scores declined by 27.3% (P < .001), whereas dyspnea severity and pain interference scores had increased by 24.5% (P < .001) and 17.1% (P < .001), respectively. Although recovery occurred over the course of the 100 days after surgery, mean physical function scores and dyspnea scores were still 12.7% (P = .02) and 26.4% (P = .001) worse, respectively, than mean preoperative levels.

CONCLUSIONS

Despite declines in QOL scores immediately after esophagectomy, recovery back toward baseline was observed during the first 100 days. These findings are of considerable importance when counseling patients regarding esophagectomy, tracking recovery, and implementing quality improvement initiatives. Further long-term follow-up is needed to determine recovery beyond 100 days.

Health-Related Quality of Life in Locally Advanced Gastric Cancer: A Systematic Review

BACKGROUND

Current treatment strategies have been designed to improve survival in locally advanced gastric cancer patients. Besides its impact on survival, treatment also affects health-related quality of life (HRQOL), but an overview of reported studies is currently lacking. The aim of this systematic review was therefore to determine the short- and long-term impact of chemotherapy, surgery, and (chemo)radiotherapy on HRQOL in locally advanced, non-metastatic gastric cancer patients.

METHODS

A systematic review was performed including studies published between January 2000 and February 2021. We extracted studies published in Medline, Embase, and Scopus databases that assessed HRQOL in patients with locally advanced, non-metastatic gastric cancer treated with curative intent. Studies using non-validated HRQOL questionnaires were excluded. Short-term and long-term HRQOL were defined as HRQOL scores within and beyond 6 months after treatment, respectively.

RESULTS

Initially, we identified 8705 articles (4037 of which were duplicates, i.e., 46%) and ultimately included 10 articles. Most studies reported that short-term HRQOL worsened in the follow-up period from 6 weeks to 3 months after surgery. However, recovery of HRQOL to preoperative levels occurred after 6 months. After completion of chemoradiotherapy, the same pattern was seen with worse HRQOL after treatment and a recovery of HRQOL after 6-12 months.

CONCLUSIONS

In patients with locally advanced, non-metastatic gastric cancer, HRQOL deteriorated during the first 3 months after surgery and chemoradiotherapy. However, the long-term data showed a recovery of HRQOL after 6-12 months. To implement HRQOL in clinical decision making in current clinical practice, more research is needed.

Comparison of Long-term Quality of Life in Patients with Esophageal Cancer after Ivor-Lewis, Mckeown, or Sweet Esophagectomy

BACKGROUND

The aim of this study was to compare the long-term quality of life (QoL) in patients after Sweet, Ivor-Lewis, or Mckeown esophagectomy.

METHODS

Esophageal cancer patients after Sweet, Ivor-Lewis, or Mckeown esophagectomy from 2010 to 2012 were included. QoL was assessed according to the European Organization for Research and Treatment of Cancer general questionnaire: QLQ-C30 and esophagus-specific questionnaire: QLQ-OES18.

RESULTS

A total of 126 qualified patients who have been alive for more than 3 years without tumor recurrence were divided into three groups: the Sweet group (n = 40), Ivor-Lewis group (n = 38), and Mckeown group (n = 48). Among these three groups, the QLQ-C30 mean scores of global health status, functional and symptom scales, and general QoL were similar. The symptom scales of QLQ-OSE18 showed that patients who had a Mckeown operation experienced more problem of eating (P = 0.029), choking when swallowing (P = 0.010) and coughing (P = 0.016), while patients undergoing Sweet operation complained more symptom of reflux (P = 0.003) and pain (P = 0.000).

CONCLUSIONS

All three types of esophagectomy provided a generally good long-term QoL. However, patients in Sweet and Mckeown group tend to suffer from a higher symptomatic burden as compared to Ivor-Lewis approach.

Quality of life after esophageal resection

Introduction

Esophageal resection is the primary treatment for malignant esophageal disease and the last resort for benign end-stage esophageal disease. There is a paucity of research comparing the long-term quality of life (QoL) following surgery among these two populations. The aim of this study was to examine the patient reported QoL after esophageal resection using questionnaires focusing on general well-being and esophageal-specific symptoms.

Methods

A prospectively maintained database of post-operatively administered European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30) with supplemental esophageal cancer-specific questionnaires (OES-18) was queried after institutional review board approval through Creighton University School of Medicine. Inclusions were made if patients received an esophageal resection for benign or malignant esophageal disease. Emergency procedures, delayed reconstructions, and stage IV disease were excluded. Student’s t-test was used for domains of function, symptoms, QoL, and esophageal-specific complaints to compare the groups with each other and with the general population.

Results

A total of 39 out of 248 patients with malignant disease and 24 out of 46 with benign disease completed the questionnaire. A mean post-operative follow-up of 53 months with a response rate of 40% was obtained. There was no difference in physical (p=0.81), role (p =0.37), conditional (p=0.73), emotional (p=0.06), or social functions (p=0.42) between the general population and the esophageal resection groups. There was also no significant difference in generalized pain (p=0.86), nausea/vomiting (p=0.27), fatigue (p=0.86), swallowing (p=0.35), or esophageal pain (p=0.12). The malignant cohort had better outcomes than the benign cohort with respect to eating (p=0.04), indigestion (p=0.04), and QoL (p=<0.01).

Discussion

The underlying disease between these cohorts is drastically different, but postoperative functional status, generalized symptoms, swallowing ability, and esophageal pain were similar. There was no difference in functional status between the general population and the esophageal resection cohorts. Patients with malignant disease reported less problems with eating and a better QoL than their benign counterparts.

Quality of life assessment in esophagectomy patients

Esophagectomy is the mainstay of curative therapy for esophageal cancer; however, it is associated with significant morbidity and mortality, with subsequent major impact on quality of life. This paper reviews the evaluation of health-related quality of life (HRQOL) in esophageal cancer patients undergoing curative intent therapy, the relationship between postoperative HRQOL and survival as well the potential utility of pre-treatment HRQOL as a prognostic tool. HRQOL assessment is valuable in helping clinicians understand the impact on patients of esophageal cancer and the various treatments thereof. HRQOL is also valuable as an end-point in studies of esophageal cancer and esophageal cancer treatment. Given the morbidity and mortality associated with the various treatments for esophageal cancer, it could be argued that HRQOL is as important an endpoint as survival, if not more so. Patient-reported pre-treatment HRQOL assessment appears to predict survival better than clinician-derived performance status assessment period. HRQOL assessment also appears to be responsive to surgical and non-surgical therapy and thus could potentially be used in trials and in practice to serve that function. Thus, HRQOL assessment could be a potentially important adjunct in shared decision-making and guiding treatment planning as well as monitoring the progress of treatment.

Long-Term Nutritional Outcome and Health Related Quality of Life of Patients Following Esophageal Cancer Surgery: A Meta-Analysis

Long term health related quality of life (HRQL) and nutritional outcome of patients following esophagectomy for cancer has become increasingly significant as the 5-year survival rate in this patient group is increasing. This meta-analysis aims to investigate the HRQOL, nutritional impact symptoms and nutritional outcomes of patients following an esophagectomy at greater than 12 months after surgery. In studies reporting on HRQL as an outcome, global QOL score at 6-month compare to greater than 12-month showed no statistically significant difference (65.92 vs. 75.78, p = 0.07). Forty-one percent of patients reported a greater than 10% weight loss at six-month follow-up (95% CI: 20-65%; I2 = 94.27, p < 0.001), and at the greater than 12-month follow-up, 33% of patients had the greater than 10% weight loss (95% CI: 15-57%; I2 = 96.18, p < 0.001). At the 12-month or longer post esophagectomy, just over half the patients reported dysphagia (51%, 95% CI: 25-76%; I2 = 95.70, p < 0.001), nausea was reported by 11% (95% CI: 7-19%; I2 = 59.31, p = 0.09), dumping syndrome reported by 60% (95% CI: 43-76%; I2 = 96.92, p < 0.001). Symptoms such as dysphagia, diarrhea, reflux, dumping syndrome, and nausea were found to persist following esophagectomy. There were insufficient robust research investigating how these symptoms impact on the adequacy of dietary intake and micronutrient status.

Impacts of treatments on the quality of life among esophageal squamous cell carcinoma patients

This study aims to investigate the effects of treatments on the quality of life for patients with esophageal squamous cell carcinoma patients diagnosed at early and late stages. From a medical center in central Taiwan, patients who had been diagnosed with esophageal squamous cell carcinoma from February 2007 and March 2011 were recruited. Using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire Core 30 (EORTC QLQ-C30) and the Quality of Life Questionnaire Oesophageal 18 (QLQ-OES18), quality of life scores for 105 esophageal squamous cell carcinoma patients were obtained and assessed. Multivariate analysis was performed on the quality of life scores after stratification by cancer stage. Among early-stage esophageal squamous cell carcinoma patients, those received only surgery (S-only) performed better in physical and social functioning compared with patients who underwent surgery and concurrent chemoradiotherapy (S+CCRT) (β = 9.0, P = 0.03; β = 12.1, P = 0.04, respectively). For those that received only concurrent chemoradiotherapy (CCRT-only), they performed worse in role and emotional functioning relative to S+CCRT patients (β = -17.2, P = 0.02; β = -15.7, P = 0.05, respectively). Among late-stage patients, CCRT-only treatment gave insignificantly better global health status and functional scale scores and less severe symptoms compared to the S+CCRT option. Better functional scores and less aggravated symptoms are observed in early-stage esophageal squamous cell carcinoma patients who received surgery-only treatment relative to those that underwent both surgery and chemoradiotherapy. For late-stage esophageal cancer patients, the measured difference of quality of life is not significant between CCRT-only and S+CCRT treatments.

Patient-Reported Outcomes in Thoracic Surgery

The existing thoracic surgical literature contains several retrospective and observational studies that include patient-reported outcomes. To deliver true patient-centered care, it will be necessary to universally gather patient-reported outcomes prospectively, including them in routine patient care, clinical registries, and clinical trials.

Systematic review of patient-reported outcome measures in the surgical treatment of patients with esophageal cancer

Esophageal cancer is currently the eighth most common cancer worldwide. Improvements in operative techniques and neoadjuvant therapies have led to improved outcomes. Resection of the esophagus carries a high risk of severe complications and has a negative impact on health-related quality of life (QOL). The aim of this study was to assess which patient-reported outcome measures (PROMs) are used to measure QOL after esophagectomy for cancer. A comprehensive search of original articles was conducted investigating QOL after surgery for esophageal carcinoma. Two authors independently selected relevant articles, conducted clinical appraisal, and extracted data (PJ and JS). Out of 5893 articles, 58 studies were included, consisting of 41 prospective and 17 retrospective cohort studies, including a total of 6964 patients. These studies included 11 different PROMs. The existing PROMs could be divided into generic, symptom-specific, and disease-specific questionnaires. The European Organisation for Research and Treatment of Cancer (EORTC) QOL Questionnaire Core 30 (QLQ C-30) along with the EORTC QLQ-OESophagus module OES18 was the most widely used; in 42 and 32 studies, respectively. The EORTC and the Functional Assessment of Cancer Therapy (FACT) questionnaires use an oncological module and an organ-specific module. One validation study was available, which compared the FACT and EORTC, showing moderate to poor correlation between the questionnaires. A great variety of PROMs are being used in the measurement of QOL after surgery for esophageal cancer. A questionnaire with a general module along with a disease-specific module for assessment of QOL of different treatment modalities seem to be the most desirable, such as the EORTC and the FACT with their specific modules (EORTC QLQ-OES18 and FACT-E). Both are developed in different treatment modalities, such as in surgical patients. With regard to reproducibility of current results, the EORTC is recommended.

Long-term quality of life after oesophagectomy with gastric conduit interposition for cancer

BACKGROUND

Gaining insight in long-term health-related quality of life more than 1year after oesophagectomy will assist clinical decision-making and inform patients about the long-term consequences of surgery.

METHODS

In this cross-sectional study, all consecutive patients who underwent oesophageal resection with gastric interposition for cancer at a tertiary referral centre between January 2007 and July 2012 were included. European Organization for Research and Treatment of Cancer (EORTC) quality of life questionnaire (QLQ)-C30 and QLQ-OES18 were sent to all patients alive without recurrence more than 1year after surgery.

RESULTS

The questionnaires were completed by 92 of 100 patients. Median duration of follow-up after surgery at completing the questionnaire was 36months (range: 12-75). Global quality of life scores were similar to a general population reference group (76±19 versus 78±17; p=0.26). However, patients scored significantly worse compared to the general population reference group on physical-, role-, cognitive- and social functioning (p<0.001). Neoadjuvant therapy and minimally invasive oesophagectomy were associated with significantly better health-related quality of life (HRQL) and symptom scores (p<0.05).

CONCLUSION

Global HRQL more than 1year after oesophagectomy with gastric tube reconstruction is comparable to the general Dutch background population, while specific functional and symptom scores are significantly worse. Neoadjuvant therapy and minimally invasive surgery are associated with quality of life benefits in long-term survivors.

Quality of life measurements as an indicator for timing of support after oesophagectomy for cancer: a prospective study

Background

Oesophagectomy is a major procedure with known side effects and reduced postoperative quality of life (QOL). It has been shown that support of patients in their new life situation is often lacking. Knowledge about how QOL changes over time is fundamental for addressing patient needs and for determining the optimal timing of supportive care. The aim of this study was to identify QOL changes over time as well as factors that may impact patient QOL during the first year after oesophagectomy for cancer.

Methods

Patients operated on for adenocarcinoma or squamous cell cancer of the oesophagus were included in this study. Seventy-nine patients completed the European Organisation for Research and Treatment of Cancer QOL questionnaires (QLQ-C30 and QLQ-OES18) before and 2, 4, 6, 9, and 12 months after surgery. A general linear model with repeated measurement analysis of variance was used for statistical testing.

Results

There was a significant QOL nadir at 2 months compared to 12 months after surgery (QLQ-C30 function scales p < 0.001, symptom scales p < 0.001, QLQ-OES18 scales p < 0.001). Treatment with proton-pump inhibitors was associated with enhanced QOL according to QLQ-C30 symptom scales (p = 0.003) and OES-18 scales (p = 0.015), but age, gender and American Society of Anaesthesiologists classification did not significantly impact QOL.

Conclusions

Patient QOL is severely hampered the first year after oesophagectomy for cancer, with a nadir at 2 months after surgery. Treatment with proton-pump inhibitors improved patient responses to symptom scales. Evidence of severely affected QOL after surgery indicates that these patients need support at an early stage after surgery. These results can be used by healthcare professionals to develop a postoperative supportive-care programme that is timed and better optimised to meet patient needs. Trial registration: EudraCT database 2009-009997-28.

Outcomes, quality of life, and survival after esophagectomy for squamous cell carcinoma: A propensity score-matched comparison of operative approaches

BACKGROUND

Minimally invasive esophagectomy (MIE) theoretically offers advantages compared with open esophagectomy (OE). However, the long-term outcomes have not been well studied, especially for esophageal squamous cell carcinoma. We retrospectively compared postoperative outcomes, quality of life (QOL), and survival in a matched population of patients undergoing MIE, with a control (OE) group.

METHODS

From May 2004 to August 2013, MIE was performed for a group of 735 patients, which was compared with a group of 652 cases of OE. Eventually, 444 paired cases, matched using propensity-score matching, were selected for further statistical analysis.

RESULTS

Compared with the OE group, the MIE group had shorter operation duration (191 ± 47 minutes vs 211 ± 44 minutes, P < .001); less blood loss (135 ± 74 ml vs 163 ± 84 ml, P < .001); similar lymph node harvest (24.1 ± 6.2 vs 24.3 ± 6.0, P = .607); shorter postoperative hospital stay (11 days [range: 7-90 days] vs 12 days [range: 8-112 days], P < .001); fewer major complications (30.4% vs 36.9%, P = .039); a lower readmission rate to the intensive-care unit (5.6% vs 9.7%, P = .023); and similar perioperative mortality (1.1% vs 2.0%, P = .281). At a median follow-up of 27 months, the 2-year overall survival rates in the MIE and OE group were: (1) stage 0 and I: 92% versus 90% (P = .864); (2) stage II: 83% versus 82% (P = .725); (3) stage III: 59% versus 55% (P = .592); (4) stage IV: 43% versus 43% (P = .802). The generalized estimating equation analysis showed that MIE had an independently positive impact on patients' postoperative QOL.

CONCLUSIONS

In our experience, MIE is a safe and effective procedure for the treatment of esophageal squamous cell carcinoma. It may offer better perioperative outcomes, better postoperative QOL, and equal oncologic survival, compared with OE.

Long-term quality of life after Ivor Lewis esophagectomy for esophageal cancer

BACKGROUND

Esophagectomy has a potentially high impact on physical, emotional, and social functions. The aim of this study was to assess long-term health-related quality of life (QOL) after esophageal cancer surgery.

METHODS

We analyzed all patients who underwent an Ivor Lewis esophagectomy for resectable esophageal cancer in our hospital from 1999 to 2010. QOL was assessed using the European Organization for Research and Treatment of Cancer general questionnaire QLQ-C30 and esophagus-specific questionnaire QLQ-OES18.

RESULTS

A total of 150 patients were operated in the surveyed 12-year period. At the time of analysis, 46 patients (31 %) were eligible for assessment, 97 patients (65 %) had died or experienced tumor recurrence, and seven patients (5 %) were lost to follow-up. Of the 46 eligible patients, 43 (94 %) returned the questionnaires. The median observation interval between the operation and QOL assessment was 40 (range 21-135) months. The QLQ-C30 mean score of global health status and general QOL was similar to that of a healthy reference population. Most of the QLQ-C30 mean scores of functional and symptom scales and QLQ-OES18 symptom scales showed a worse result than for a healthy reference population. The highest mean scores were reflux and eating problems.

CONCLUSIONS

In the long term, Ivor Lewis esophagectomy provides a generally good QOL for patients with esophageal cancer, which is comparable to a healthy reference population. However, some patients suffer from significant symptoms. Reflux and eating problems were the most relevant complaints. Dietary counseling is therefore important in the postoperative course.

Quality of life in patients with esophageal cancer receiving definitive chemoradiotherapy or esophagectomy

The aim of the present study was to assess the variation in the quality of life (QOL) of patients with esophageal cancer receiving definitive chemoradiotherapy or esophagectomy, and to explore the main factors that affects QOL. A total of 102 patients with esophageal cancer receiving definitive chemoradiotherapy or esophagectomy were assessed using a QOL questionnaire, and a numeric score was calculated in each conceptual area and compared with reference data by a statistical method. With regards to the impacts on the QOL, the chemoradiotherapy had less of an impact compared with esophagectomy. The QOL declined following the two treatments, but was restored in a specific period of time. In the present study, the main factors that affected the QOL of patients included physical function, fatigue and pain. Definitive chemoradiotherapy is therefore superior to esophagectomy with regard to its effect on the QOL. The two treatments had an effect on the QOL of patients, but this effect was temporary and was resumed after a period of time.

Annual computed tomography scans do not improve outcomes following esophagectomy for cancer: a 10-year UK experience

Evidence for the best approach to follow-up patients after esophagectomy for cancer is scant and conflicting, and has led to a wide variety in practice. The aim of this study was to evaluate whether our annual routine computed tomography (aCT) scan program changes outcomes. A retrospective review of 169 patients who underwent esophagectomy for cancer in our unit between 2001 and 2010 was performed. aCT scan was part of follow-up in all patients to 5 years. Minimum follow-up was 37 months. The primary outcome measure was survival. Recurrence was detected in 61 cases (36%). aCT scan diagnosed recurrence in only a minority of cases (17 cases, 28%). In the majority of patients, clinical evidence prompted an unplanned CT scan (uCT; 44 cases, 72%). There was no difference in unadjusted survival between the two groups (hazard ratio = 0.61, 95% confidence interval 0.34-1.08, P = 0.090), nor was one more likely to receive secondary oncological treatment (aCT 41% vs. uCT 44%, P = 1.000). When we adjusted survival patterns for confounding covariates, the uCT cohort showed a protective effect (hazard ratio = 0.54, 95% confidence interval 0.28-0.98, P = 0.042). These data suggest that aCT scans do not influence management or survival after esophagectomy. A consensus follow-up protocol for patients treated for esophageal cancer remains to be established.

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.

Tailoring esophageal cancer surgery

Esophageal cancer is a significant source of major mortality worldwide and is increasing dramatically in incidence. Without treatment this disease leads rapidly to death, but intervention also carries significant risk, so a carefully tailored approach must be used to maximize oncological efficacy while minimizing the negative consequences of intervention. Careful patient selection based on histologic and anatomic staging, consideration of each patient's clinical variables, appropriately timing chemo- and radiation therapy, and minimizing the morbidity of surgical intervention may significantly improve a patient's chances of surviving this disease, but each must be carefully orchestrated with a tailored approach to treatment. This review will serve as a guide to tailoring surgery for esophageal cancer.

The impact of neoadjuvant chemoradiotherapy on perioperative outcomes, tumor pathology, and survival in clinical stage II and III esophageal cancer

BACKGROUND

The purpose of this study was to evaluate the impact of neoadjuvant chemoradiotherapy (NCR) on perioperative outcomes, tumor pathology, and survival following surgical resection of clinical stage II and III esophageal cancer.

METHODS

Patients undergoing esophagectomy for clinical stage II and III cancer were divided into two groups: those who received NCR and those who underwent primary surgery (1991-2011).

RESULTS

A total of 173 (50.9%) of 340 stage II/III patients received NCR, 108 (31.8%) patients underwent primary surgery, and 59 (17.4%) underwent neoadjuvant chemotherapy followed by surgery. Patients who received NCR were younger but had a similar Charlson comorbidity index and incidence of adenocarcinoma. There were no differences between groups in the incidence of complications, in-hospital mortality, and ICU stay, but patients who received NCR demonstrated a reduced length of hospital stay. NCR was associated with a reduced the incidence of positive pathological lymph node status and positive resection margin (3.1 vs. 21.1%) in stage III esophageal cancer. No overall survival benefit was seen with use of NCR, although a nonsignificant improvement in survival of 22 months (p = 0.06) was noted in patients with adenocarcinoma. Negative resection margin was associated with an improved survival in both stage II and III patients.

CONCLUSIONS

This study highlights the importance of planning operations to optimize the opportunity to provide negative surgical resection margins and to identify patients not responding to NCR to allow them to proceed directly to surgery. Additional assessment of the effect of NCR on patients with adenocarcinoma is warranted.

The choice of primary repair or mesh repair for paraesophageal hernia: a decision analysis based on utility scores

BACKGROUND

Controversy exists on the use of mesh in the repair of paraesophageal hernias (PEH). This debate centers around the type of mesh used, its value in preventing recurrence, its short- and long-term complications, and the consequences of those complications compared with primary repair. Decision analysis is a method to account for the important aspects of a clinical decision. The purpose of this study was to determine whether or not the addition of mesh would be superior in PEH repair.

METHODS

A decision analysis model of the choice between primary repair and mesh repair of a PEH was constructed. The essential features of the decision were the rate of perioperative complications, PEH recurrence rate, reoperation rate after recurrence, rate of symptomatic recurrence, and type of outcome after reoperation. The literature was reviewed to obtain data for the decision analysis and the average rates used in the baseline analysis. A utility score was used as the outcome measure, with a perfect outcome receiving a score of 100 and death 0. Sensitivity analysis was used to determine if changing the rates of recurrence or reoperation changed the dominant treatment.

RESULTS

Using the baseline analysis, mesh repair was slightly superior to primary repair (utility score 99.59 vs 99.12, respectively). However, if recurrence rates were similar, primary repair would be slightly superior; whereas if reoperation rates were similar, mesh repair would be superior. Using sensitivity analysis, there are combinations of recurrence rates and reoperation rates that would make one repair superior to the other. However, these differences are relatively small.

CONCLUSIONS

Depending on what the decision-maker accepts as the recurrence and reoperation rates for these types of repair, either mesh or primary repair may be the treatment of choice. However, the differences between the two are small, and, perhaps, clinically inconsequential.

Targeting therapy for esophageal cancer in patients aged 70 and over

BACKGROUND

While cancer is a disease of the elderly, these patients are under-represented in randomized trials. Esophageal cancer-management in the elderly is challenging because of the morbidity and mortality associated with surgery.

OBJECTIVES

We examined a strategy of neo-adjuvant chemo-radiotherapy (naCRT), followed by surgery or surveillance, in selected patients with cancer aged 70 and older.

METHODS

A prospectively-accrued database identified 56 consecutive patients over a 90-month period, who were aged 70years and over, presented with esophageal carcinoma and were treated with neo-adjuvant CRT (naCRT)±surgery.

RESULTS

Of 129 eligible patients, 66 (51%) received palliative measures, while 63 (49%) had curative intervention, namely 7 had surgery and 56 had naCRT±surgery. Of these 56 patients, 33 (59%) had adenocarcinoma (AC) and 23 (41%) had squamous cell carcinoma (SCC). Twenty-five (45%) had a complete clinical response (cCR), of which 6 had immediate resection; 4 (67%) had a complete pathological response (pCR); 19 patients with a cCR declined or were unfit for surgery and underwent surveillance; of these, 3 had interval esophagectomy; 16 were not offered or declined resection. Eight (50%) have survived ≥3years. Mean overall survival was 28months for the entire cohort; 47months for cCRs; 61months for patients undergoing primary resection, 46months for cCRs who did not undergo resection and 29months for those undergoing interval resection for recurrent disease. In cCRs, surgery did not provide a survival advantage (p=0.861).

CONCLUSION

cCR yields an overall 3-year survival of 50% without operation. As 45% of patients have a cCR to naCRT, obligatory resection in high-risk cCR patients makes little sense. With the option for salvage esophagectomy in re-emergent disease, this selective strategy is an attractive alternative for elderly patients with cancer.

Article Commentary: Management of Barrett's Esophagus

Barrett's esophagus is a pathologic change of the normal squamous epithelium of the esophagus to specialized columnar metaplasia. Barrett's esophagus is a result of prolonged exposure of the esophagus to gastroduodenal refluxate. Although Barrett's itself is not symptomatic, and, in fact, patients with Barrett's esophagus may be completely asymptomatic, it does identify patients at higher risk of developing esophageal adenocarcinoma. Traditionally, antireflux surgery was reserved for patients with symptoms, because it was believed that antireflux surgery did not eliminate Barrett's esophagus and reduce cancer risk. Rationale for the treatment of Barrett's esophagus beyond treating symptoms of gastroesophageal reflux disease stems from the hope to decrease, if not eliminate, the risk of adenocarcinoma. Treatment options ranged from medical acid suppression without surveillance to resection. Ablation, particularly endoscopic radio-frequency ablation, has become the standard of care for Barrett's esophagus with high-grade dysplasia. It role in nondysplastic or low-grade dysplastic Barrett's is less clear. Combined endoscopic mucosal resection with ablation is effective in nodular high-grade Barrett's esophagus. Resection should be reserved for patients with persistent high-grade dysplasia despite multiple attempts at endoscopic ablation or resection or for patients with evidence of carcinoma.

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.

Health-related quality of life among 5-year survivors of esophageal cancer surgery: a prospective population-based study

PURPOSE

To clarify whether health-related quality of life (HRQL) can be restored in 5-year survivors of esophageal cancer surgery.

PATIENTS AND METHODS

The nationwide Swedish prospective and population-based cohort for this study consisted of patients with esophageal cancer who were treated surgically between 2001 and 2005 and were alive 5 years after surgery. The European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire C30 (EORTC QLQ-C30) and EORTC QLQ-OES18 (the disease site-specific module for esophageal cancer) were used to assess HRQL 6 months, 3 years, and 5 years postoperatively. Paired t tests were used to evaluate changes in HRQL over time. Patients' HRQL was classified as improved, stable, or deteriorated. Multivariable linear regression was used to calculate mean score difference in HRQL with 95% CIs between patients and a background population according to HRQL category.

RESULTS

Among 153 eligible patients alive after 5 years, 117 (76%) answered all HRQL assessments. Among a random sample of 6,969 Swedish adults representing the corresponding background population, 4,910 (70.5%) participated. For most patients, HRQL remained stable or improved over time, and their HRQL was comparable to that of the background population. Patients who deteriorated over time reported large and clinically significant mean score differences for all measures. For example, 5 years after surgery, physical function was stable or improved in 86% of patients and their mean score (87) was similar to that of the background population (88), but the 14% who deteriorated had a substantially lower mean score of 56.

CONCLUSION

HRQL recovers to a level comparable to that in the background population in most patients who survive 5 years after esophagectomy for cancer, although a subgroup of patients has substantially worse HRQL.

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.