The association of pretreatment health-related quality of life with surgical complications for patients undergoing open surgical resection for colorectal cancer

Pretreatment Health-Related Quality-of-Life Status and Survival in Pancreatobiliary Surgical Patients

BACKGROUND

Pancreatobiliary (PB) disorders, especially cancer, negatively affect patients' health-related quality of life (HRQoL). However, the influence of baseline, preintervention HRQoL on perioperative and oncologic outcomes has not been well defined. We hypothesized that low baseline HRQoL is associated with worse perioperative and long-term survival outcomes for PB surgical patients.

STUDY DESIGN

Pretreatment Functional Assessment of Cancer Therapy - Hepatobiliary Survey results and clinical data from PB patients (2008 to 2016) from a single center's prospective database were analyzed. Survey responses were aggregated into composite scores and divided into quintiles. Patients in the highest quintile of HRQoL were compared to patients in the bottom four quintiles combined. Overall survival (OS) and disease-free survival (DFS) were analyzed using the Kaplan-Meier method. Logistic and Cox regressions were used to determine associations between quintiles of HRQoL scores and 30-day complications and long-term survival, respectively.

RESULTS

Of 162 patients evaluated, 99 had malignancy, and 63 had benign disease. Median follow-up was 31 months. Baseline HRQoL scores were similar for benign and malignant disease (p = 0.42) and were not associated with the development of any (p = 0.08) or major complications (p = 0.64). Patients with highest quintile HRQoL scores had improved 3-year OS (84.6 vs 61.7%, p = 0.03) compared to patients in the lowest four quintiles of HRQoL. Among cancer patients only, those with the highest quintile scores had improved 3-year OS (81.6 vs 47.4%, p = 0.02). On multivariable analysis, highest quintile HRQoL scores were associated with longer OS and DFS for patients with malignancy.

CONCLUSIONS

Pretreatment HRQoL was associated with both OS and DFS among PB patients and might have prognostic utility. Future studies are necessary to determine whether patients with poorer HRQoL may benefit from targeted psychosocial interventions.

Can baseline quality of life scores predict for morbidity and survival after CRS and HIPEC: a prospective study of 151 patients

Objectives

Various studies have shown that good quality of life (QoL) can be achieved after cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). There is prognostic value of baseline QoL in post-operative outcome in Western setting. Our prospective study aims to validate these observations and elucidate clinical factors that predict poorer QoL in Asian peritoneal carcinomatosis patients.

Methods

European Organization for Research and Treatment of Cancer Core Quality of Life Questionnaire was administered to patients before CRS and HIPEC and thereafter at 3, 6 and 12 months.

Results

A total of 151 patients underwent 155 surgeries. Four hundred and seventy two questionnaires were completed. Median disease-free survival (DFS) was 16.5 months. Three year DFS and overall survival (OS) were 24.0% and 73.0% respectively. Post-operative global health status significantly increased at 3, 6 and 12 months. The decreases in functional scales recovered to baseline by 1-year post-surgery. Peritoneal carcinomatosis index (PCI), presence of stoma, peritonectomy duration, death within one year, post-operative complication and length of SICU stay negatively influenced QoL. Complication rates were higher in patients with lower global health status, physical and role functioning scores and higher symptom summary scores at baseline. Lower social functioning score, and higher pain, dyspnoea and symptom summary scores at baseline were significantly associated with poorer OS.

Conclusions

Various clinical factors can help us predict a patient’s QoL after surgery. Several baseline factors were also able to predict morbidity and survival. Going forward, we can use these factors to help us better select patients who will have a greater benefit from CRS and HIPEC.

Psychosocial Determinants of Readmission After Surgery

BACKGROUND

Quality of life and psychosocial determinants of health, such as health literacy and social support, are associated with increased health care utilization and adverse outcomes in medical populations. However, the effect on surgical health care utilization is less understood.

OBJECTIVE

We sought to examine the effect of patient-reported quality of life and psychosocial determinants of health on unplanned hospital readmissions in a surgical population.

RESEARCH DESIGN

This is a prospective cohort study using patient interviews at the time of hospital discharge from a Veterans Affairs hospital.

SUBJECTS

We include Veterans undergoing elective inpatient general, vascular, or thoracic surgery (August 1, 2015-June 30, 2017).

MEASURES

We assessed unplanned readmission to any medical facility within 30 days of hospital discharge.

RESULTS

A total of 736 patients completed the 30-day postoperative follow-up, and 16.3% experienced readmission. Lower patient-reported physical and mental health, inadequate health literacy, and discharge home with help after surgery or to a skilled nursing or rehabilitation facility were associated with an increased incidence of readmission. Classification regression identified the patient-reported Veterans Short Form 12 (SF12) Mental Component Score <31 as the most important psychosocial determinant of readmission after surgery.

CONCLUSIONS

Mental health concerns, inadequate health literacy, and lower social support after hospital discharge are significant predictors of increased unplanned readmissions after major general, vascular, or thoracic surgery. These elements should be incorporated into routinely collected electronic health record data. Also, discharge plans should accommodate varying levels of health literacy and consider how the patient's mental health and social support needs will affect recovery.

Burden of illness in not adequately controlled chronic hypoparathyroidism: Findings from a 13-country patient and caregiver survey

OBJECTIVE

To address knowledge gaps regarding burdens associated with not adequately controlled chronic hypoparathyroidism.

DESIGN

Global patient and caregiver survey.

STUDY POPULATIONS

Patients with chronic hypoparathyroidism not adequately controlled on conventional therapy and their caregivers.

MEASUREMENTS

Health-related quality of life (HRQoL) and health status were evaluated using the 36-item Short Form version 2 (SF-36 v2.0) and Five-Level EuroQoL 5 Dimensions (EQ-5D-5L) instruments, respectively. Hypoparathyroidism-associated symptoms were assessed by a disease-specific Hypoparathyroidism Symptom Diary and caregiver burden via the Modified Caregiver Strain Index (MCSI).

RESULTS

Data were obtained from 398 patients and 207 caregivers. Patients' self-rated hypoparathyroidism-related symptom severity was none (3%), mild (32%), moderate (53%) or severe (12%). Per the Hypoparathyroidism Symptom Diary, patients reported moderate, severe or very severe symptoms of physical fatigue (73%), muscle cramps (55%), heaviness in limbs (55%) and tingling (51%) over a 7-day recall period. Impacts (rated 'somewhat' or 'very much') were reported by 84% of patients for ability to exercise, 78% for sleep, 75% for ability to work and 63% for family relationships. Inverse relationships were observed between patient self-rated overall symptom severity and HRQoL and health status assessment scores-the greater the symptom severity, the lower the SF-36 and EQ-5D-5L scores. Caregiver burden increased with patient self-rated symptom severity: none, 1.7 MCSI; mild, 5.4 MCSI; moderate, 9.5 MCSI; and severe, 12.5 MCSI.

CONCLUSION

Patients with not adequately controlled hypoparathyroidism reported substantial symptoms and impacts. Greater patient symptom severity was associated with decreased patient HRQoL and health status assessments and increased caregiver burden.

Severity of Postoperative Complications From the Perspective of the Patient

Background:

Although provider-derived surgical complication severity grading systems exist, little is known about the patient perspective.

Objective:

To assess patient-rated complication severity and determine concordance with existing grading systems.

Methods:

A survey asked general surgery patients to rate the severity of 21 hypothetical postoperative events representing grades 1 to 5 complications from the Accordion Severity Grading System. Concordance with the Accordion scale was examined. Separately, descriptive ratings of 18 brief postoperative events were ranked.

Results:

One hundred sixty-eight patients returned a mailed survey following their discharge from a general surgery service. Patients rated grade 4 complications highest. Grade 1 complications were rated similarly to grade 5 and higher than grades 2 and 3 (P ≤ .01). Patients rated one event not considered an Accordion scale complication higher than all but grade 4 complications (P < .001). The brief events also did not follow the Accordion scale, other than the grade 6 complication ranking highest.

Conclusion:

Patient-rated complication severity is discordant with provider-derived grading systems, suggesting the need to explore important differences between patient and provider perspectives.

Timely access to care in the treatment of rectal cancer and the effect on quality of life

AIM

The aim of this study was to investigate if a delay in a patient's first contact with a healthcare professional, and any subsequent delay in diagnosis, affected self-assessed quality of life prior to start of treatment for rectal cancer.

METHOD

Questionnaires were administered when patients had been informed of the diagnosis and planned treatment. The primary end-point was self-assessed quality of life according to a seven-point Likert scale. The response variables were dichotomized and analysed by unadjusted and adjusted binary logistic regression.

RESULTS

A reported duration of symptoms longer than 4 months was found to be associated with a lower quality of life than a reported duration of symptoms of less than 3 months. Furthermore, a reported period of longer than 2 months from first contact with a healthcare professional to a diagnosis was found to correlate with lower quality of life compared with a period shorter than 2 months. However, when adjusting for possible confounding variables the duration of symptoms and time to diagnosis were not found to affect self-assessed quality of life. Several variables were found to have significant influence in the statistical model, including sense of coherence, the presence of negative intrusive thoughts, comorbidity, depressed mood, male sex and comorbidity.

CONCLUSION

One conclusion of our study is that further efforts to shorten delay in rectal cancer care with the aim of improving quality of life may be futile. To improve the patient's quality of life at diagnosis other interventions should be considered, such as screening for depression and/or negative intrusive thoughts.

The impact of complications on prolonged length of hospital stay after resection in colorectal cancer: A retrospective study of Taiwanese patients

Objectives To assess the impact of minor, major and individual complications on prolonged length of hospital stay in patients with colorectal cancer (CRC) after surgery using multivariate models. Methods This was a retrospective review of data from patients who underwent surgery for stage I-III CRC at two medical centres in southern Taiwan between 2005-2010. Information was derived from four databases. Multivariate logistic regression methods were used to assess the impact of complications on prolonged length of stay (PLOS) and prolonged postoperative length of stay (PPOLOS). Results Of 1658 study patients, 251 (15.1%) experienced minor or major postsurgical complications during hospitalizations. Minor and major complications were significantly associated with PLOS (minor, odds ratio [OR] 3.59; major, OR 8.82) and with PPOLOS (minor, OR 5.55; major, OR 10.00). Intestinal obstruction, anastomosis leakage, abdominal abscess and bleeding produced the greatest impact. Conclusions Minor and major complications were stronger predictors of prolonged hospital stay than preoperative demographic and disease parameters. Compared with the PLOS model, the PPOLOS model better predicted risk of prolonged hospital stay. Optimal surgical and medical care have major roles in surgical CRC patients.

A systematic review of prehabilitation programs in abdominal cancer surgery

INTRODUCTION

Prehabilitation programs aim to optimise patients in order to enhance post-operative recovery. This study aims to review the composition of prehabilitation programs for patients undergoing major abdominal cancer surgery and define the outcome measures that are used to evaluate this intervention.

METHODS

A systematic literature review of all comparative studies on prehabilitation versus standard care in patients undergoing abdominal cancer surgery was performed in accordance with PRISMA guidelines. Literature search was performed using Medline, OVID, EMBASE, Google Scholar, and Cochrane databases. Outcomes of interest included prehabilitation program composition (exercise, nutritional, and psychological interventions), duration, mode of delivery, and outcome measures used to determine impact of prehabilitation versus standard care.

RESULTS

9 studies (7 randomised controlled and 2 prospective non-randomised trials) comprising of 549 patients (281 prehabilitation versus 268 standard care) were included in this review. 5 studies reported patients undergoing surgery for colorectal cancer, 2 for bladder tumours, 1 for liver resections, and 1 involving unspecified abdominal oncological operations. The 6 min walk test (6MWT) was used in 4 studies to measure functional capacity with a threshold of >20 m improvement at 4-8 weeks post-operatively deemed significant (distance range from 278 to 560 m). Changes in anaerobic threshold and VO₂^max with prehabilitation were evaluated in 5 studies (ml/kg/min). Health-related quality of life was evaluated using SF-36 system, anxiety assessed using hospital anxiety and depression score (HADS). Post-operative complications were classified according to the Clavien-Dindo classification with no significant difference between prehabilitation and standard care groups.

CONCLUSION

Prehabilitation programs in patients undergoing abdominal cancer surgery remain heterogeneous in their composition, mode of administration, outcome measures of functional capacity that are used to evaluate their impact. All these aspects require standardisation prior to the evaluation of prehabilitation on a larger scale.

Quality-of-Life Evaluation After Cytoreductive Surgery with Hyperthermic Intraperitoneal Chemotherapy

BACKGROUND

Cytoreductive surgery (CS) with hyperthermic intraperitoneal chemotherapy (HIPEC) for peritoneal metastases can alleviate symptoms and prolong survival at the expense of morbidity and quality of life (QoL). This study aimed to monitor QoL and outcomes before and after HIPEC.

METHODS

A prospective QoL trial of patients who underwent HIPEC for peritoneal metastases from 2000 to 2015 was conducted. The patients completed the Medical Outcomes Study 36-Item Short-Form Health Survey (SF-36), the Functional Assessment of Cancer Therapy + Colon Subscale (FACT-C), the Brief Pain Inventory, the Center for Epidemiologic Studies Depression scale, and the Eastern Cooperative Oncology Group (ECOG) performance status at baseline, then 3, 6, 12, and 24 months after HIPEC. The trial outcome index (TOI) was analyzed. Proportional hazards modeled the effect of baseline QoL on survival.

RESULTS

The 598 patients (53.8 % female) in the study had a mean age of 53.3 years. The overall 1-year survival rate was 76.8 %, and the median survival period was 2.9 years. The findings showed a minor morbidity rate of 29.3 %, a major morbidity rate of 21.7 %, and a 30-day mortality rate of 3.5 %. The BPI (p < 0.0001) and worst pain (p = 0.004) increased at 3 months but returned to baseline at 6 months. After CS + HIPEC, FACT-C emotional well-being, SF-36 mental component score, and emotional health improved (all p < 0.001). Higher baseline FACT-General (hazard ratio [HR], 0.92; 95 % confidence interval [CI], 0.09-0.96), FACT-C (HR, 0.73; 95 % CI 0.65-0.83), physical well-being (HR, 0.71; 95 % CI 0.64-0.78), TOI (HR, 0.87; 95 % CI 0.84-0.91), and SF-36 vitality (HR, 0.88; 95 % CI 0.83-0.92) were associated with improved survival (all p < 0.001). Higher baseline BPI (HR, 1.1; 95 % CI 1.05-1.14; p < 0.0001), worst pain (HR, 1.06; 95 % CI 1.01-1.10; p = 0.01), and ECOG (HR, 1.74; 95 % CI 1.50-2.01; p < 0.0001) were associated with worse survival.

CONCLUSIONS

Although HIPEC is associated with morbidity and detriments to QoL, recovery with good overall QoL typically occurs at or before 6 months. Baseline QoL is associated with morbidity, mortality, and survival after HIPEC.

The impact of postoperative complications on the recovery of elderly surgical patients

BACKGROUND

While the negative impact of postoperative complications on hospital costs, survival, and cancer recurrence is well known, few studies have quantified the impact of postoperative complications on patient-centered outcomes such as functional status. The objective of this study was to estimate the impact of postoperative complications on recovery of functional status after elective abdominal surgery in elderly patients.

METHODS

Elderly patients (70 years and older) undergoing elective abdominal surgery, with a planned length of stay >1 day, were prospectively enrolled between July 2012 and December 2014. The primary outcome was time to recovery to the preoperative functional status measured by the short physical performance battery (SPPB) preoperatively and at 1 week, 1, 3, and 6 months after surgery. The comprehensive complication index was calculated to grade the severity and number of postoperative complications. A Weibull survival model with interval censoring was performed, controlling for age, sex, body mass index (BMI), comorbidities (Charlson comorbidity index-CCI), frailty, presence of cancer, nutritional status, wound class, preoperative functional status, and surgical approach.

RESULTS

Hundred and forty-nine patients (79 men and 70 women) were included in the analysis. Mean age was 77.7 ± 4.9 years, mean BMI was 27.2 ± 5.5 kg/m(2), and the median CCI was 3 (IQR 2-6). The mean preoperative SPPB score was 9.62 ± 2.33. A total of 52 patients (34.9 %) experienced one or more postoperative complications, including four mortalities, and a total of 72 complications. The mean comprehensive complication index score for these patients was 25.7 ± 23.8. In the presence of all other variables included in the model, a higher comprehensive complication index score was found to significantly decrease the hazard of recovery (HR 0.96, CI 0.94-0.98, p value = 0.0004) and hence increase the time to recovery.

CONCLUSION

Following elective abdominal surgery, elderly patients who experience a greater number and more severe postoperative complications take longer to return to their preoperative functional status.

Pretreatment Dysphagia Inventory and videofluorographic swallowing study as prognostic indicators of early survival outcomes in head and neck cancer

BACKGROUND

The prognostic role of swallowing-related, pretreatment subjective and objective findings has not been investigated in detail. The authors evaluated the association between pretreatment MD Anderson Dysphagia Inventory (MDADI) or videofluorographic swallowing study (VFSS) results and standard outcomes, including early recurrence and survival, in patients with treatment-naïve head and neck squamous cell carcinoma (HNSCC).

METHODS

Patients with HNSCC (n = 191) who received treatment at the authors' institution and were examined by self-administered MDADI questionnaires and VFSS were prospectively enrolled. MDADI and VFSS findings were analyzed in correlation with clinicopathologic variables, and factors that predicted 2-year disease-free survival (DFS) and overall survival (OS) were identified using a Cox proportional-hazards regression model.

RESULTS

The 2-year OS and DFS rates were 80.1% and 77.5%, respectively. Clinical tumor (T) and lymph node (N) classifications, overall TNM stage, sex, tumor site, and educational level were significantly associated with specific MDADI subdomains, whereas Karnofsky performance score was significantly associated with all MDADI subdomains. After controlling for clinical factors, total scores, global assessment scores, and emotional and physical MDADI subscores were significantly predictive of 2-year OS and DFS (P < .05 for each). VFSS findings were not significantly associated with survival (P > .05).

CONCLUSIONS

The current results provide evidence of the prognostic role of the MDADI in predicting early survival outcomes in patients with HNSCC. The MDADI may be a practical and noninvasive method for the identification of patients at risk who would benefit from close follow-up.

Systematic review of the impact of surgical harm on quality of life after general and gastrointestinal surgery

OBJECTIVE

To assess the impact of surgical harm on quality of life (QoL) in general and gastrointestinal surgery.

BACKGROUND

Surgical adverse events (SAEs) are associated with poor outcome. Although SAEs are likely to affect QoL, this has not been demonstrated in surgery.

METHODS

Studies in general and gastrointestinal surgery measuring postoperative QoL in patients who suffered SAEs were identified. The overall impact of SAEs on QoL scores was determined by combining results from different studies. Component scores, adjustment for confounders, and time trends were evaluated.

RESULTS

Data from 57,058 patients in 31 studies were analyzed. Most studies assessed the combined effect of different SAEs. High-quality studies adjusted for preoperative QoL. When different QoL instruments were scaled down to a common 0 to 1 score, the mean difference in QoL between SAE and no-SAE patients was 0.140 in esophagectomy, 0.110 in the Crohn resection, 0.089 in colorectal resection, 0.085 in gastric bypass, 0.072 in cholecystectomy, and 0.060 in inguinal hernia repair. Studies evaluating ileal pouch formation and antireflux surgery showed conflicting results. SAEs did not significantly affect QoL in emergency laparotomy and pancreatectomy. The frequency of SAEs was 5% to 48%. Physical QoL was affected more than emotional QoL.

CONCLUSIONS

Significantly negative effects of SAEs on QoL were demonstrated in a range of procedures. Postoperative QoL seems to be a surrogate for the severity of impact of SAEs on patients. QoL may be an important utility to evaluate the economic and societal impact of SAEs thereby defining the threshold for safe practice.

Prehabilitation versus rehabilitation: a randomized control trial in patients undergoing colorectal resection for cancer

BACKGROUND

The preoperative period (prehabilitation) may represent a more appropriate time than the postoperative period to implement an intervention. The impact of prehabilitation on recovery of function al exercise capacity was thus studied in patients undergoing colorectal resection for cancer.

METHODS

A parallel-arm single-blind superiority randomized controlled trial was conducted. Seventy-seven patients were randomized to receive either prehabilitation (n = 38) or rehabilitation (n = 39). Both groups received a home-based intervention of moderate aerobic and resistance exercises, nutritional counseling with protein supplementation, and relaxation exercises initiated either 4 weeks before surgery (prehabilitation) or immediately after surgery (rehabilitation), and continued for 8 weeks after surgery. Patients were managed with an enhanced recovery pathway. Primary outcome was functional exercise capacity measured using the validated 6-min walk test.

RESULTS

Median duration of prehabilitation was 24.5 days. While awaiting surgery, functional walking capacity increased (≥ 20 m) in a higher proportion of the prehabilitation group compared with the rehabilitation group (53 vs. 15%, adjusted P = 0.006). Complication rates and duration of hospital stay were similar. The difference between baseline and 8-week 6-min walking test was significantly higher in the prehabilitation compared with the rehabilitation group (+23.7 m [SD, 54.8] vs. -21.8 m [SD, 80.7]; mean difference 45.4 m [95% CI, 13.9 to 77.0]). A higher proportion of the prehabilitation group were also recovered to or above baseline exercise capacity at 8 weeks compared with the rehabilitation group (84 vs. 62%, adjusted P = 0.049).

CONCLUSION

Meaningful changes in postoperative functional exercise capacity can be achieved with a prehabilitation program.

The impact of postoperative complications on long-term quality of life after curative colorectal cancer surgery

OBJECTIVE

To investigate the effect that complications have on patients' long-term quality of life (QoL) after curative colorectal cancer surgery.

BACKGROUND

Colorectal cancer surgery is a high risk, with approximately 1 in 3 patients suffering a complication. The long-term consequences of postoperative complications are important but have poorly been documented.

METHODS

The MRC-CLASICC trial (laparoscopic-assisted vs open surgery for colorectal cancer) included prospective evaluation of QoL using validated scoring questionnaires: EORTC QLQ-C30/CR38 and EQ5D. These were used to compare QoL at 3, 6, 18, and 36 months to baseline values for patients categorized into 2 groups: (i) those suffering any complication and (ii) those suffering any of 5 common complications (wound, chest, anastomotic leak, hemorrhage, and cardiac event).

RESULTS

A total of 614 of 794 CLASICC patients were suitable for inclusion. Complications occurred in 215 (35.0%) patients, including: wound complications (61, 9.9%), chest infection (50, 8.1%), anastomotic leak (27, 4.4%), hemorrhage (14, 2.3%), and cardiac event (26, 4.2%). Significant long-term differences in QoL between patients with and without complications were found for Physical and Social Function, Role Functioning, and Body Image on EORTC QLQ-C30/QLQ-CR38 analysis and Mobility, Self-care, and Pain/Discomfort on EQ5D analysis. No significant differences were seen for emotional/cognitive functioning, global QoL, financial difficulties, or future perspectives. Risk factors of age, gender, ASA (American Society of Anesthesiologists) grade, and stoma moderated the impact of complications in the short- to medium-term QoL, but had less influence on long-term QoL.

CONCLUSIONS

Postoperative complications have adverse effects on long-term QoL, particularly for Physical, Role and Social Functioning, and Body Image, as well as for Mobility, Self-care, and Pain/Discomfort. These findings should inform future preoperative counseling and health care planning.

Preoperative quality of life and surgical outcomes in gynecologic oncology patients: a new predictor of operative risk?

OBJECTIVE

Quality of life (QoL) for women with gynecologic malignancies is predictive of chemotherapy related toxicity and overall survival but has not been studied in relation to surgical outcomes and hospital readmissions. Our goal was to evaluate the association between baseline, pre-operative QoL measures and 30-day post-operative morbidity and health resource utilization by gynecologic oncology patients.

METHODS

We analyzed prospectively collected survey data from an institution-wide cohort study. Patients were enrolled from 8/2012 to 6/2013 and medical record data was abstracted (demographics, comorbid conditions, and operative outcomes). Responses from several validated health-related QoL instruments were collected. Bivariate tests and multivariable linear and logistic regression models were used to evaluate factors associated with QoL scores.

RESULTS

Of 182 women with suspected gynecologic malignancies, 152 (84%) were surveyed pre-operatively and 148 (81%) underwent surgery. Uterine (94; 63.5%), ovarian (26; 17.5%), cervical (15; 10%), vulvar/vaginal (8; 5.4%), and other (5; 3.4%) cancers were represented. There were 37 (25%) cases of postoperative morbidity (PM), 18 (12%) unplanned ER visits, 9(6%) unplanned clinic visits, and 17 (11.5%) hospital readmissions (HR) within 30days of surgery. On adjusted analysis, lower functional well-being scores resulted in increased odds of PM (OR 1.07, 95%CI 1.01-.1.21) and HR (OR 1.11, 95%CI 1.03-1.19). A subjective global assessment score was also strongly associated with HR (OR 1.89, 95%CI 1.14, 3.16).

CONCLUSION

Lower pre-operative QoL scores are significantly associated with post-operative morbidity and hospital readmission in gynecologic cancer patients. This relationship may be a novel indicator of operative risk.

Predicting postoperative morbidity following cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CS+HIPEC) with preoperative FACT-C (Functional Assessment of Cancer Therapy) and patient-rated performance status

BACKGROUND

Cytoreductive surgery with hyperthermic intraperitoneal chemotherapy (CS+HIPEC) is associated with significant perioperative morbidity. One goal of our ongoing patient-reported health-related quality of life (HRQoL) program is to describe the prognostic value of HRQoL measures for predicting postoperative morbidity and mortality following CS+HIPEC.

METHODS

A retrospective analysis of a prospectively collected clinical database for all patients treated for peritoneal carcinomatosis and who participated in our patient-reported HRQoL program from 2001 to 2011 was done. Patients completed the Functional Assessment of Cancer Therapy questionnaire plus the colon symptom subscale, in addition to the Eastern Cooperative Oncology Group (ECOG) performance status rating prior to CS+HIPEC. The trial outcome index (TOI), a specific measure of function, symptoms, and physical well being of the patient, was analyzed. The TOI is a combination of the physical and functional well being subscales + the colon-specific subscale of the FACT-C.

RESULTS

Of 855 patients, 387 (45.2 %) participated in the HRQoL trials. Mean age was 53.3 years, and 213 (55 %) were female versus 174 (45 %) males. There were 240 patients (62 %) who had a complication versus 147 (38 %) who had no complication. A 30-day mortality rate of 7.7 % (30) was documented. Patients who suffered a 30-day postoperative mortality demonstrated a lower mean preoperative score in the FACT-C TOI 52.7 versus 61.7; P < 0.001. Independent predictors of 30-day mortality on multivariate analysis included TOI (0.05), age (0.001), and smoking (0.001). Patients with a higher TOI score were less likely to suffer a mortality (95 % CI 0.9-1.0, P = 0.05). Patients with a higher emotional well being (EWB) score were less likely to suffer a complication 0.9 (95 % CI 0.87-1.0, P = 0.04). Other independent predictors of postoperative morbidity included diabetic status (P = 0.05), ECOG performance status (0.001), and gender (0.02).

CONCLUSIONS

Preoperative HRQoL, as measured by FACT-C and ECOG performance status and added to traditional factors, helps predict postoperative morbidity and mortality following CS+HIPEC.

The Feasibility and Effects of Acupuncture on Quality of Life Scores During Chemotherapy in Ovarian Cancer: Results from a Pilot, Randomized Sham-Controlled Trial

BACKGROUND

Within a pilot trial regarding chemotherapy-induced neutropenia, the secondary aim of the main study was explored. This involved measuring the effects-as shown on two key measurement scales reflecting quality of life (QoL)-of verum versus sham acupuncture on patients with ovarian cancer during chemotherapy.

OBJECTIVE

The aim of this substudy was to determine the feasibility of determining the effects of verum acupuncture versus sham acupuncture on QoL in patients with ovarian cancer during chemotherapy.

DESIGN

This was a randomized, sham-controlled trial.

SETTING

The trial was conducted at two cancer centers.

PATIENTS

Patients with ovarian cancer (N=21) who were receiving chemotherapy-primarily intravenous carboplatin and paclitaxel-participated in this substudy.

INTERVENTION

The participants were given either active or sham acupuncture 1 week prior to cycle 2 of chemotherapy. There were ten sessions of acupuncture, with manual and electro-stimulation over a 4-week period.

MAIN OUTCOME MEASURES

The European Organization for Research and Treatment of Cancer-Quality-of-Life Questionnaire-Core 30 Item (EORTC-QLQ-C30) and the Quality of Life Questionnaire-Ovarian Cancer Module-28 Item (QLQ-OV28) were administered to the patients at baseline and at the end of their acupuncture sessions.

RESULTS

Of the original 21, 15 patients (71%) completed the study, and 93% of them completed the questionnaires. The EORTC-QLQ-C30 subscores were improved in the acupuncture arm, including the mean scores of social function (SF), pain, and insomnia (p=0.05). However, after adjusting for baseline differences, only the SF score was significantly higher in the active acupuncture arm, compared with the sham acupuncture arm (p=0.03).

CONCLUSIONS

It appears feasible to conduct a randomized sham-controlled acupuncture trial measuring QoL for patients with ovarian cancer who are undergoing chemotherapy. Acupuncture may have a role in improving QoL during chemotherapy.

Comprehensive geriatric assessment can predict complications in elderly patients after elective surgery for colorectal cancer: a prospective observational cohort study

OBJECTIVE

To examine the association between the outcomes of a pre-operative comprehensive geriatric assessment (CGA) and the risk of severe post-operative complications in elderly patients electively operated for colorectal cancer.

METHODS

One hundred seventy-eight consecutive patients ≥ 70 years electively operated for all stages of colorectal cancer were prospectively examined. A pre-operative CGA was performed, and patients were categorized as fit, intermediate, or frail. The main outcome measure was severe complications within 30 days of surgery.

RESULTS

Twenty-one patients (12%) were categorized as fit, 81 (46%) as intermediate, and 76 (43%) as frail. Eighty-three patients experienced severe complications, including three deaths; 7/21 (33%) of fit patients, 29/81 (36%) of intermediate patients and 47/76 (62%) of frail patients (p=0.002). Increasing age and ASA classification were not associated with complications in this series.

CONCLUSION

CGA can identify frail patients who have a significantly increased risk of severe complications after elective surgery for colorectal cancer.

Comorbidity, age, race and stage at diagnosis in colorectal cancer: a retrospective, parallel analysis of two health systems

BACKGROUND

Stage at diagnosis plays a significant role in colorectal cancer (CRC) survival. Understanding which factors contribute to a more advanced stage at diagnosis is vital to improving overall survival. Comorbidity, race, and age are known to impact receipt of cancer therapy and survival, but the relationship of these factors to stage at diagnosis of CRC is less clear. The objective of this study is to investigate how comorbidity, race and age influence stage of CRC diagnosis.

METHODS

Two distinct healthcare populations in the United States (US) were retrospectively studied. Using the Cancer Care Outcomes Research and Surveillance Consortium database, we identified CRC patients treated at 15 Veterans Administration (VA) hospitals from 2003-2007. We assessed metastatic CRC patients treated from 2003-2006 at 10 non-VA, fee-for-service (FFS) practices. Stage at diagnosis was dichotomized (non-metastatic, metastatic). Race was dichotomized (white, non-white). Charlson comorbidity index and age at diagnosis were calculated. Associations between stage, comorbidity, race, and age were determined by logistic regression.

RESULTS

342 VA and 340 FFS patients were included. Populations differed by the proportion of patients with metastatic CRC at diagnosis (VA 27% and FFS 77%) reflecting differences in eligibility criteria for inclusion. VA patients were mean (standard deviation; SD) age 67 (11), Charlson index 2.0 (1.0), and were 63% white. FFS patients were mean age 61 (13), Charlson index 1.6 (1.0), and were 73% white. In the VA cohort, higher comorbidity was associated with earlier stage at diagnosis after adjusting for age and race (odds ratio (OR) 0.76, 95% confidence interval (CI) 0.58-1.00; p = 0.045); no such significant relationship was identified in the FFS cohort (OR 1.09, 95% CI 0.82-1.44; p = 0.57). In both cohorts, no association was found between stage at diagnosis and either age or race.

CONCLUSION

Higher comorbidity may lead to earlier stage of CRC diagnosis. Multiple factors, perhaps including increased interactions with the healthcare system due to comorbidity, might contribute to this finding. Such increased interactions are seen among patients within a healthcare system like the VA system in the US versus sporadic interactions which may be seen with FFS healthcare.

Health-related quality of life assessment at presentation may predict complications and early relapse in patients with localized cancer of the esophagus

Health-related quality of life (HR-QOL) assessment in esophageal cancer is increasingly performed. However, the association of baseline HR-QOL in predicting outcome is unclear. This study aimed to assess the impact of HR-QOL scores at diagnosis with major morbidity, mortality, failure to progress to surgery, recurrence within 1 year, and survival in patients with localized esophageal cancer. The European Organization for Research and Treatment of Cancer's quality of life questionnaire was completed at diagnosis. Univariate and multivariate logistic regression were used to investigate the relationship between baseline HR-QOL and outcomes adjusting for confounding variables. A total of 185 patients with localized esophageal cancer were included, 89 undergoing multimodal therapy and 96 surgery alone. Global QOL scores were significantly associated with in-hospital mortality (P = 0.020) but not with major morbidity (P = 0.709) or 1-year survival (P = 0.247). Symptoms of fatigue and dyspnea at baseline were significantly (P < 0.05) associated with major morbidity, in-hospital mortality, and survival in univariate analysis. After adjusting for known confounding variables in multivariate analysis, only worse dyspnea score remained predictive of in-hospital mortality and a worse fatigue score remained predictive of 1-year survival. HR-QOL was of no benefit in predicting survival in multivariate analysis that identified pathological nodal status as the most significant factor. HR-QOL questionnaires may be helpful in preoperative assessment of risk. It is possible that patients with unrecognized micrometastatic disease at the time of surgery may report worse systemic symptoms at diagnosis, in particular fatigue and dyspnea, and these and global QOL scores may also identify poorer reserves that may increase in-hospital morbidity and mortality postoperatively.

Validation of Patient's Self-Reported Social Functioning As an Independent Prognostic Factor for Survival in Metastatic Colorectal Cancer Patients: Results of an International Study by the Chronotherapy Group of the European Organisation for Research and Treatment of Cancer

Purpose

A recent study identified a prognostic model for survival in metastatic colorectal cancer patients which included WBC count, alkaline phosphatase (AP), number of metastatic sites, and patients’ self-reported social functioning. The aim of this research is to validate this model on data from an independent sample.

Patients and Methods

This validation study is based on a prospective randomized controlled trial in patients with metastatic colorectal cancer conducted by the European Organisation for Research and Treatment of Cancer (EORTC) Chronotherapy Group. Overall, 564 patients in 10 countries were enrolled. For the purpose of this independent validation, patients with health-related quality of life (HRQOL) baseline data were analyzed. HRQOL was assessed using the EORTC Quality of Life Questionnaire C30 (QLQ-C30). The Cox proportional hazards regression model was used for both univariate and multivariate analyses of survival.

Results

The previous model with an additional adjustment, by stratification for sex, was replicated and its parameters were confirmed to independently predict survival: WBC count with an hazard ratio (HR) of 1.31 (95% CI, 1.021 to 1.698; P = .034); AP with an HR of 1.53 (95% CI, 1.188 to 1.979; P = .001); number of sites involved with an HR of 1.90 (95% CI, 1.531 to 2.364; P < .0001); and patients’ self-reported social functioning with an HR of 0.94 (95% CI, 0.905 to 0.976; P = .001). The latter translates into a 6% increase in the likelihood of an earlier death for every 10-point decrease in the social functioning scale of the EORTC QLQ-C30.

Conclusion

This study provides confirmatory evidence of the independent prognostic value of patients’ self-reported social functioning in patients with advanced colorectal cancer.

Quality of life after rectal resection and multimodality therapy

Modern management of locally advanced rectal cancer requires a multimodality approach. This includes radical surgery, pelvic radiotherapy, and systemic chemotherapy. It can require a permanent colostomy and result in significant bowel, sexual, and urinary dysfunction. In order to determine the effectiveness of various multimodality regimens it is important to not only assess conventional oncologic outcomes but also the impact on patient's quality of life.

Patient personality predicts postoperative stay after colorectal cancer resection

OBJECTIVE

Postoperative length of stay (LOS) is an important outcome after colorectal cancer surgery. The aim of this study was to evaluate the putative effects of personality, mood, coping and quality of life on LOS.

METHOD

A consecutive series of 110 eligible patients undergoing elective resection for colorectal cancer were invited to participate in the study. A battery of psychometric questionnaires including the Hospital Anxiety and Depression Scale, the Functional Assessment of Cancer Therapy (colorectal), the Courtauld Emotional Control Scale, the Positive and Negative Affectivity Scale and the Eysenck Personality Questionnaire (EPQ) were administered 5-12 days before surgery. Nonparametric correlations were computed for psychometric scores, demographic variables and the LOS. Factors found to be significantly correlated on this analysis were entered into a multiple regression model to determine the independent predictors of LOS.

RESULTS

One hundred and four patients with colorectal cancer participated. Seventy were male (67%) and the mean age was 68 years (range 39-86). The median LOS was 10 days (range 4-108). LOS was negatively correlated with pre- and postoperative albumin levels, PANAS +ve affect, Functional Assessment of Cancer Therapy questionnaire with the colorectal module functional well-being score and EPQ extroversion score. LOS was strongly positively correlated with postoperative morbidity. LOS was positively correlated with CECS anger score, age and being male. Postoperative morbidity (beta = 0.379, P = 0.007) and extroversion (beta = -0.318, P = 0.05) were independent predictors of LOS.

CONCLUSION

Personality as measured by EPQ predicts postoperative LOS in patients with colorectal cancer. Extroverts have a higher pain threshold and this may be part of the explanation.

An audit of outcomes in colorectal cancer in China

AIM

This study was designed to analyses the correlation between the extent of lymph node excision and the prognosis of colorectal cancer and to discuss the clinical significance of excision of lymph nodes adjacent to mesenteric artery pedicle.

METHODS

A total of 1409 patients with colorectal cancer who had the primary radical operation in our hospital during 1985 to 2000 was analyzed in this study. They were divided into two groups according to whether undergone an excision of lymph nodes adjacent to mesenteric artery pedicle. There were 857 patients in the excision group and 552 patients in the non-excision group. Comparison of prognoses was based on the follow-up results.

RESULTS

The 1-year, 3-year and 5-year overall survival rates of the excision group were 90%, 81% and 77%, while those of the non-excision group were 91%, 84% and 79%, respectively. The 1-year, 3-year and 5-year tumor-free survival rates of excision group were 90%, 79% and 75%, while those of the non-excision group were 90%, 83% and 76%. Kaplan-Meier analysis did not show any difference in overall survival rate or tumor-free survival rate between these two groups (P>0.05). After follow-up of 12 to 289 months there were 42 cases of local recurrence and 79 cases of metastases in the excision group. In the non-excision group local recurrence occurred in 30 cases and 60 patients had metastases. There was no difference in the rates of local recurrence and metastasis between these two groups. Multivariate correlation analyses showed that the excision of lymph nodes adjacent to mesenteric artery pedicle was not statistically correlated to recurrence, metastasis and survival time after radical operation of colorectal cancer.

CONCLUSION

In radical operation of colorectal cancer it is not necessary to perform excision of lymph nodes adjacent to mesenteric artery pedicle which is not correlated to prognosis.

Patient-centered outcomes after therapy for colorectal cancer

In practical terms, clinicians can use the results of patient-centered outcome instruments to track patients' functional status and quality-of-life changes through treatment. Noting formalized results might help clinicians better communicate with patients at critical times during treatment, especially with regard to patient expectations.Although numerous clinical variables of uncertain value are regularly followed, validated functional and quality-of-life results have been put to use only rarely in the clinical setting. Clinicians' ability to interpret and apply quality-of-life results will surely improve with practice, and likely would be well worth the contribution to our patients' well-being.

Gender differences in quality of life of patients with rectal cancer. A five-year prospective study

To determine how quality of life changes over time and to assess gender-related differences in quality of life of rectal cancer patients we conducted a 5-year study. Little is known about how quality of life (QoL) changes over time in patients after surgery for rectal cancer, and whether gender of the patients is associated with a different perception of QoL. The aim of this study was to assess prospectively, changes in quality of life after surgery for rectal cancer, with a focus on gender related differences. Over a 5-year period, the EORTC-QLQ-C-30 and a tumor-specific module were prospectively administered to patients before surgery, at discharge, 3, 6, 12, and 24 months postoperatively. Comparisons were made between female and male patients. A total of 519 patients participated in the study, 264 men and 255 women. The two groups were comparable in terms of surgical procedures, adjuvant treatment, tumor stage, and histology. Most QoL scores dropped significantly below baseline in the early postoperative period. From the third month onward, global health, emotional and physical functioning, improved. Female gender was associated with significantly worse global health and physical functioning and with higher scores on treatment strain and fatigue. Men reported difficulties with sexual enjoyment; furthermore, over time, sexual problems created high levels of strain in men, worse than baseline levels in the early postoperative period. These problems tended to continue over the course of time. The findings in this study confirm that QoL changes after surgery and differs between men and women. Women appear to be affected by impaired physical functioning and global health. Female gender is associated with significantly higher fatigue levels and increased strain values after surgery. Through impaired sexual enjoyment, men are put more under strain than woman.

Association between quality of life scores and short-term outcome after surgery for cancer of the oesophagus or gastric cardia

BACKGROUND

Evidence suggests that baseline quality of life (QOL) scores are independently prognostic for survival in patients with cancer, but the role of QOL data in predicting short-term outcome after surgery is uncertain. This study assessed the association between QOL scores and short-term outcomes after surgery for oesophageal and gastric cancer.

METHODS

Consecutive patients selected for oesophagectomy or total gastrectomy between November 2000 and May 2003 completed the European Organization for Research and Treatment of Cancer's quality of life questionnaire, QLQ-C30. Multivariable regression models, adjusting for known clinical risk factors, were used to investigate relationships between QOL scores, major morbidity, hospital stay and survival status at 6 months.

RESULTS

Of 130 patients, 121 completed the questionnaire (response rate 93.1 per cent). There were 29 major complications (24.0 per cent) and 22 patients (18.2 per cent) died within 6 months of operation. QOL scores were not associated with major morbidity but were significantly related to survival status at 6 months after adjusting for known clinical risk factors. A worse fatigue score of 10 points (scale 0-100) corresponded to an increase in the odds of death within 6 months of surgery of 37.4 (95 per cent confidence interval (c.i.) 12.4 to 67.8) per cent (P = 0.002). Pretreatment social function scores were moderately associated with hospital stay (P = 0.021); a reduction in social function by 10 points corresponded to an increase in hospital stay of 0.93 (95 per cent c.i. 0.12 to 1.74) days.

CONCLUSION

QOL scores supplement standard staging procedures for oesophageal and gastric cancer by providing prognostic information, but they do not contribute to perioperative risk assessment.

Quality of life in colorectal cancer patients with colectomy and the validation of the Functional Assessment of Cancer Therapy-Colorectal (FACT-C), Version 4

The purpose of this study was to determine whether the Functional Assessment of Cancer Therapy-Colorectal (the FACT-C), a disease-specific tool for the assessment of colorectal cancer patients' QOL, is a valid assessment tool for measuring QOL changes. Ninety-eight colorectal cancer patients performed the assessment at baseline and 52 of these patients completed the instrument at one month and six months after colectomy. In addition to the FACT-C, the shortened forms of the Profile of Mood States, the Eastern Cooperative Oncology Group Performance Status Rating, Neuroticism Scale in the Eysenck Personality Questionnaire, and Functional Living Index-Cancer were completed. We found convergent and divergent validity and good reliability of the FACT-C. Patients' overall QOL was lower at one month after colectomy and recovered to the pre-surgery level at six months after colectomy.

Ten-year historic cohort of quality of life and sexuality in patients with rectal cancer

PURPOSE

In various studies, type of surgery, age, and gender had different impact on sexuality and quality of life in patients with rectal cancer. This study was designed to investigate how sexuality and quality of life are affected by age, gender, and type of surgery.

METHODS

A total of 516 patients who had undergone surgery for rectal cancer in our department from 1992 to 2002 were included. Within one year after the operation, 117 patients died. Questionnaires were sent to 373 patients 12 to 18 months after surgery. We received quality of life data from 261 patients. Comparisons were made after adjusting age, gender, and type of surgical procedure.

RESULTS

For patients receiving abdominoperineal resection sexuality was most impaired. Significant differences were seen in symptom and function scales between males and females. Females reported more distress from the medical treatment insomnia, fatigue, and constipation. Both genders had impaired sexual life; however, males had significantly higher values and felt more distressed by this impairment. Younger females felt more distress through impaired sexuality. In males sexuality was impaired independent of age. Adjuvant therapy had no influence on sexuality but on quality of life one year after surgery.

CONCLUSIONS

Assessing quality of life with general and specific instruments is helpful to determine whether patients improved through the treatment. The study showed that gender, age, and type of surgery influence sexuality and that quality of life after surgery for rectal cancer is impacted. Because quality of life is a predictor for complications and survival, availability of such data may help to direct supportive treatment to improve outcome.

Impact of Age on Quality of Life in Patients with Rectal Cancer

Some studies indicate that age at the time of surgery has a general effect on outcomes. The impact of age on the quality of life (QOL) of patients with rectal cancer, however, has not been investigated. The present study was conducted to address this issue. Over a 5-year period the European Organization for Research and Treatment of Cancer (EORTC)-QLQ-C-30 and a tumor-specific module were prospectively administered to patients before surgery, at discharge, and at 3, 6, 12, and 24 months postoperatively. Comparisons were made between age groups. A total of 519 patients participated in the study. QOL data were available for 253 patients. Significant differences were observed only between patients aged 69 years and younger (< or =69 years) (169/253) and those aged 70 years and older (> or =70 years) (85/253). Physical and role functioning was better for patients < or =69 years; patients > or =70 years suffered from increased pain and fatigue. Younger patients had more difficulty with sexual enjoyment, and over time sexual strain was worse for patients aged > or =70 years during the early postoperative period but improved, whereas patients aged < or =69 years had increasing levels of strain over time. The findings in this study confirmed that QOL is dynamic over time and that age has an impact on QOL and sexuality. Patients aged > or =70 years are affected by impaired physical functioning, global health, and fatigue, whereas increased treatment strain during the early postoperative period improves over time. Patients aged < or =69 years experience increased strain because of impaired sexual function.