Quality of life in long-term survivors after curative transhiatal oesophagectomy for oesophageal carcinoma

Functional syndromes and symptom-orientated aftercare after esophagectomy

BACKGROUND

Surgery is the cornerstone of esophageal cancer treatment but remains burdened with significant postoperative changes of gastrointestinal function and quality of life.

PURPOSE

The aim of this narrative review is to assess and summarize the current knowledge on postoperative functional syndromes and quality of life after esophagectomy for cancer, and to provide orientation for the reader in the challenging field of functional aftercare.

CONCLUSIONS

Post-esophagectomy syndromes include various conditions such as dysphagia, reflux, delayed gastric emptying, dumping syndrome, weight loss, and chronic diarrhea. Clinical pictures and individual expressions are highly variable and may be extremely distressing for those affected. Therefore, in addition to a mostly well-coordinated oncological follow-up, we strongly emphasize the need for regular monitoring of physical well-being and gastrointestinal function. The prerequisite for an effective functional aftercare covering the whole spectrum of postoperative syndromes is a comprehensive knowledge of the pathophysiological background. As functional conditions often require a complex diagnostic workup and long-term therapy, close interdisciplinary cooperation with radiologists, gastroenterologists, oncologists, and specialized nutritional counseling is imperative for successful management.

Perioperative risk factors of psychological distress in patients undergoing treatment for esophageal cancer

Background

Esophageal cancer patients often feel depressed and are fearful of metastasis and death. The objective of this study was to clarify the characteristics of patients with psychological distress at all 5 time points compared with patients with no psychological distress especially from standpoints of personal coping styles and QOL.

Methods

In total, 102 of 152 consecutive patients who attended the outpatient clinic at Toranomon Hospital between April 2017 and April 2019 met eligibility criteria for inclusion in this study. Questionnaires designed to identify psychological distress (HADS-scores) and assess QOL (EORTC QLQ C-30/OES18) were administered at 5 time points from the time of the first outpatient consultation to 3 months after esophagectomy. The questionnaire of coping strategies (MAC-scales) was administered at only time 1 point.

Results

Based on the trends of HADS-scores, we defined two groups: “persistent high-HAD scores” and “persistent low-HADS scores.” There are strong relationships between psychological distress and coping strategy, and psychological distress and QOL. The possibility that there are relationships between stress coping strategies and some QOL status depending on some point of treatment.

Conclusions

The psychological distress during the treatment course of esophageal cancer is significantly associated with the coping strategies and QOL influenced by esophagectomy. This study can provide baseline information for identifying patients in need of psychological management and paves the way for larger clinical studies in the future.

Relationship between psychological distress and health-related quality of life at each point of the treatment of esophageal cancer

BACKGROUND

Patients with esophageal cancer often feel depression or fear of death influenced by multiple clinical factors. This study sought to investigate the clinical factors associated with psychological distress, focusing on the influence of health-related quality of life (HRQOL) for better psychological management of patients with esophageal cancer.

METHODS

In total, 102 of 152 consecutive patients surgically treated at Toranomon Hospital met the eligibility criteria for analysis. Questionnaires designed to identify psychological distress and QOL (EORTC QLQ C-30/OES18) were administered at five time points during the treatment course. Degree of psychological distress was assessed by Hospital Anxiety and Depression Scale (HADS).

RESULTS

Patients with HADS score ≥ 11 at each visit showed significantly higher level of symptoms or problems measured by the score of EORTC QLQ C-30/OES18 compared with those with HADS score ≤ 10. Emotional status was a significant factor associated with psychological distress at all times. Although functional scales including global health status or QOL status and symptom scales associated with esophageal cancer were strongly associated with psychological distress before treatment, scales associated with changes in habitus after esophagectomy showed significant correlation with psychological distress after surgery. No significant correlation was observed between psychological distress and individual baseline characteristics, apart from history of surgery and pathological staging.

CONCLUSIONS

Psychological distress during treatment course of esophageal cancer is significantly associated with HRQOL influenced by esophagectomy. The current results may warrant prospective intervention through enhanced recovery after surgery to better manage patients undergoing highly invasive procedures for esophageal cancer.

Do esophageal cancer survivors work after esophagectomy and do health problems impact their work? A cross-sectional study

PURPOSE

This study aimed to evaluate the occupational status and work impediments due to health problems in long-term esophageal cancer survivors.

METHODS

The Short-Form Health and Labour Questionnaire (SF-HLQ) was sent to esophageal cancer survivors. Primary outcomes included the number of working esophageal cancer survivors and the patient-reported impact of health problems on work, as evaluated by the SF-HLQ. Patient and treatment characteristics were compared between survivors who worked and survivors who did not work at the time of follow-up after esophagectomy.

RESULTS

The SF-HLQ was sent to 98 survivors and was completed by 86 of them. Of the 86 included survivors, 35 worked at the time of cancer diagnosis and 18 worked at a median follow-up of 48 months [range 23-87] after treatment. Survivors who worked at the time of follow-up were younger at the time of treatment when compared to survivors who had quit working after their cancer diagnosis (58.4 vs. 64.2 years, P = 0.006). Working survivors most commonly reported reduced work pace (44%), a self-imposed need to work in seclusion (33%), and concentration problems (28%) due to health problems at work. The majority of working survivors (93%) reported an efficiency score ≥ 8 on a scale from 1 (lowest efficiency) to 10 (highest efficiency).

CONCLUSIONS

Nearly half of the esophageal cancer survivors who worked at the time of diagnosis also worked at a median follow-up of 48 months after esophagectomy. Despite health problems impacting work, most esophageal cancer survivors reported high efficiency at work.

IMPLICATIONS FOR CANCER SURVIVORS

Esophageal cancer survivors can often work with high efficiency, despite potential health problems.

Patient-Reported Outcomes in Surgical Oncology: An Overview of Instruments and Scores

Traditional measures of quality and effectiveness in surgical oncology have focused on morbidity, mortality, and when available, recurrence rates. Measuring patient-reported outcomes (PROs) has become more widely accepted during the last decade. This article reviews instruments commonly used in the surgical treatment of cancer patients to evaluate PROs. In addition, it discusses the linkage of PROs and health-related quality of life measures with traditional surgical complications and highlights future directions related to the expanding use of PROs in the surgical care of cancer patients.

Neoadjuvant chemoradiotherapy plus surgery versus active surveillance for oesophageal cancer: a stepped-wedge cluster randomised trial

BACKGROUND

Neoadjuvant chemoradiotherapy (nCRT) plus surgery is a standard treatment for locally advanced oesophageal cancer. With this treatment, 29% of patients have a pathologically complete response in the resection specimen. This provides the rationale for investigating an active surveillance approach. The aim of this study is to assess the (cost-)effectiveness of active surveillance vs. standard oesophagectomy after nCRT for oesophageal cancer.

METHODS

This is a phase-III multi-centre, stepped-wedge cluster randomised controlled trial. A total of 300 patients with clinically complete response (cCR, i.e. no local or disseminated disease proven by histology) after nCRT will be randomised to show non-inferiority of active surveillance to standard oesophagectomy (non-inferiority margin 15%, intra-correlation coefficient 0.02, power 80%, 2-sided α 0.05, 12% drop-out). Patients will undergo a first clinical response evaluation (CRE-I) 4-6 weeks after nCRT, consisting of endoscopy with bite-on-bite biopsies of the primary tumour site and other suspected lesions. Clinically complete responders will undergo a second CRE (CRE-II), 6-8 weeks after CRE-I. CRE-II will include 18F-FDG-PET-CT, followed by endoscopy with bite-on-bite biopsies and ultra-endosonography plus fine needle aspiration of suspected lymph nodes and/or PET- positive lesions. Patients with cCR at CRE-II will be assigned to oesophagectomy (first phase) or active surveillance (second phase of the study). The duration of the first phase is determined randomly over the 12 centres, i.e., stepped-wedge cluster design. Patients in the active surveillance arm will undergo diagnostic evaluations similar to CRE-II at 6/9/12/16/20/24/30/36/48 and 60 months after nCRT. In this arm, oesophagectomy will be offered only to patients in whom locoregional regrowth is highly suspected or proven, without distant dissemination. The main study parameter is overall survival; secondary endpoints include percentage of patients who do not undergo surgery, quality of life, clinical irresectability (cT4b) rate, radical resection rate, postoperative complications, progression-free survival, distant dissemination rate, and cost-effectiveness. We hypothesise that active surveillance leads to non-inferior survival, improved quality of life and a reduction in costs, compared to standard oesophagectomy.

DISCUSSION

If active surveillance and surgery as needed after nCRT leads to non-inferior survival compared to standard oesophagectomy, this organ-sparing approach can be implemented as a standard of care.

Effect of Neoadjuvant Chemoradiotherapy on Health-Related Quality of Life in Esophageal or Junctional Cancer: Results From the Randomized CROSS Trial

Purpose

To compare pre-agreed health-related quality of life (HRQOL) domains in patients with esophageal or junctional cancer who received neoadjuvant chemoradiotherapy (nCRT) followed by surgery or surgery alone. Secondary aims were to examine the effect of nCRT on HRQOL before surgery and the effect of surgery on HRQOL.

Patients and Methods

Patients were randomly assigned to nCRT (carboplatin plus paclitaxel with concurrent 41.4-Gy radiotherapy) followed by surgery or surgery alone. HRQOL was measured using the European Organisation for Research and Treatment of Cancer Quality of Life Questionnaire–Core 30 (QLQ-C30) and –Oesophageal Cancer Module (QLQ-OES24) questionnaires pretreatment and at 3, 6, 9, and 12 months postoperatively. The nCRT group also received preoperative questionnaires. Physical functioning (PF; QLQ-C30) and eating problems (EA; QLQ-OES24) were chosen as predefined primary end points. Predefined secondary end points were global QOL (GQOL; QLQ-C30), fatigue (FA; QLQ-C30), and emotional problems (EM; QLQ-OES24).

Results

A total of 363 patients were analyzed. No statistically significant differences in postoperative HRQOL were found between treatment groups. In the nCRT group, PF, EA, GQOL, FA, and EM scores deteriorated 1 week after nCRT (Cohen’s d: −0.93, P < .001; 0.47, P < .001; −0.84, P < .001; 1.45, P < .001; and 0.32, P = .001, respectively). In both treatment groups, all end points declined 3 months postoperatively compared with baseline (Cohen’s d: −1.00, 0.33, −0.47, −0.34, and 0.33, respectively; all P < .001), followed by a continuous gradual improvement. EA, GQOL, and EM were restored to baseline levels during follow-up, whereas PF and FA remained impaired 1 year postoperatively (Cohen’s d: 0.52 and −0.53, respectively; both P < .001).

Conclusion

Although HRQOL declined during nCRT, no effect of nCRT was apparent on postoperative HRQOL compared with surgery alone. In addition to the improvement in survival, these findings support the view that nCRT according to the Chemoradiotherapy for Esophageal Cancer Followed by Surgery Study–regimen can be regarded as a standard of care.

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.

A national audit of colonic interposition for esophageal replacement

Esophageal replacement by colonic interposition is an uncommon procedure. This study sought to identify the frequency of this operation in England, identify techniques and associated problems, and also assess health-related quality of life (HR QOL) from the two largest centers performing this procedure. Hospital Episode Statistics were used to identify patients and centers undertaking colon interposition between March 2001 and March 2015. An online survey of UK consultants discussed methods and experience. HR QOL was assessed using the Short Form 36(SF-36v2) with additional gastrointestinal questions. Hospital Episode Statistics identified 328 interpositions (22 in pediatric hospitals). The two highest volume units did 42 and 45 operations, respectively. Thirty-four surgeons (79% response rate) replied to the survey. Fifty-two percent preferred to use the left colon with 81% preferring a substernal placement. The HR QOL survey was performed on 24 patients with a median of 3 years after surgery (ranging from 9 months to 10 years) from the two largest centers and a 56% response rate. Five patients had physical QOL scores above population average and 10 had mental scores above population average. All patients had early satiety, 20 described dysphagia, and 18 regularly took antireflux medication. There was an estimated mean loss of 13.1% body weight (10.6 kg) postoperatively and three patients still relied on a feeding tube for nutrition after an average of 3 years. Colon interposition results in an acceptable long-term QOL. Few centers regularly perform this operation, and centralizing to high-volume centers may lead to better outcomes.

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.

In-vivo oesophageal regeneration in a human being by use of a non-biological scaffold and extracellular matrix

BACKGROUND

Tissue-engineered extracellular matrix populated with autologous pluripotent cells can result in de-novo organogenesis, but the technique is complex, not widely available, and has not yet been used to repair large oesophageal defects in human beings. We aimed to use readily available stents and extracellular matrix to regenerate the oesophagus in vivo in a human being to re-establish swallowing function.

METHODS

In a patient aged 24 years, we endoscopically placed a readily available, fully covered, self-expanding, metal stent (diameter 18 mm, length 120 mm) to bridge a 5 cm full-thickness oesophageal segment destroyed by a mediastinal abscess and leading to direct communication between the hypopharynx and the mediastinum. A commercially available extracellular matrix was used to cover the stent and was sprayed with autologous platelet-rich plasma adhesive gel. The sternocleidomastoid muscle was placed over the matrix. After 4 weeks, stent removal was needed due to stent migration, and was replaced with three stents telescopically aligned to improve anchoring. The stents were removed after 3·5 years and the oesophagus was assessed by endoscopy, biopsy, endoscopic ultrasonography, and high-resolution impedance manometry.

FINDINGS

After stent removal we saw full-thickness regeneration of the oesophagus with stratified squamous epithelium, a normal five-layer wall, and peristaltic motility with bolus transit. 4 years after stent removal, the patient was eating a normal diet and maintaining a steady weight.

INTERPRETATION

Maintenance of the structural morphology of the oesophagus with off-the-shelf non-biological scaffold and stimulation of regeneration with commercially available extracellular matrix led to de-novo structural and functional regeneration of the oesophagus.

FUNDING

None.

Long-term quality of life after surgery for adenocarcinoma of the esophagogastric junction: extended gastrectomy or transthoracic esophagectomy?

BACKGROUND

Esophagectomy with gastric tube reconstruction and extended transhiatal gastrectomy with Roux-en-Y reconstruction are alternative procedures in current therapeutic concepts for adenocarcinoma of the esophagogastric junction (AEG). The impact of these operations on long-term health-related quality of life (HRQL) is incompletely understood.

METHODS

Patients with cancer-free survival of at least 24 months after esophagectomy (ESO) or extended gastrectomy (GAST) for AEG were identified from a prospectively maintained database. EORTC questionnaires were sent out to assess health-related general (QLQ-C30) and cancer-specific (OG-25) quality of life. Numeric scores were calculated for each conceptual area and compared with those of healthy reference populations.

RESULTS

123 patients (ESO n = 71; GAST n = 52) completed the self-rated questionnaires. HRQL was consistently lower in surgical patients (GAST and ESO) compared with healthy reference populations. Also, there was a general trend for a better HRQL in GAST compared with ESO patients. This trend was statistically significant for physical function (p = 0.04), dyspnea (p = 0.02), and reflux (p = 0.03). Subgroup analysis revealed no significant differences between patients with or without prior neoadjuvant therapy.

CONCLUSIONS

After mid- and long-term follow-up, HRQL after extended gastrectomy with Roux-en-Y reconstruction is superior to that after esophagectomy and gastric tube reconstruction. Improved HRQL after gastrectomy is mainly due to less pulmonary and reflux-related symptoms. Our findings may influence the choice of the surgical strategy for patients with AEG.

Aspects of emotional functioning following oesophageal cancer surgery in a population-based cohort study

OBJECTIVE

The aim of this study was to establish the proportion of patients reporting emotional problems following oesophagectomy for cancer and identify the risk characteristics for emotional problems.

METHODS

A Swedish population-based cohort study of patients with surgically treated oesophageal cancer was used. The European Organization for Research and Treatment of Cancer Quality of Life Questionnaire C30 was used to assess tension, worry, irritation and depressed mood at 6 months and 5 years after surgery. Potential risk characteristics were retrieved from medical notes and data linkages to Swedish health registries. Multivariable logistic regression analyses were performed to examine risk characteristics for poor emotional recovery.

RESULTS

Of 401 patients included at 6 months, 49% reported problems with tension, 61% worry, 62% irritation and 63% depressed mood. Of the 140 (35%) patients who completed the 5-year follow-up, 39% reported problems with tension and about half of the patients reported problems with worry, irritation, and depressed mood (49, 45 and 52%, respectively). Squamous cell carcinoma was identified as a risk characteristic for tension (OR 2.15, 95% CI 1.30-3.55), worry (OR 2.02, 95% CI 1.19-3.40) and depressed mood (OR 1.71, 95% CI 1.01-2.90) at 6 months compared with adenocarcinoma. Compared with higher education, lower education was associated with tension (upper secondary schooling: OR 1.97, 95% CI 1.02-3.79 and 9-year compulsory: OR 2.46, 95% CI 1.28-4.74), while non-cohabitating patients were less likely to report problems with worry at 6 months (OR 0.53, 95% CI 0.34-0.84) compared with cohabitating patients.

CONCLUSIONS

A substantial proportion of patients reports emotional problems following oesophagectomy, and risk characteristics include squamous cell carcinoma histology and low educational level.

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.

Long-term health related quality of life following intensive care during treatment for haematological malignancies

Objective

Long-term health-related quality of life (HRQoL) was determined for patients admitted to the haematology ward who needed intensive care treatment (H-IC+) and compared with those who did not (H-IC−) as well as with that for patients admitted to the general ICU (nH-IC+).

Methods

A cross-sectional study was carried out median 18 months after admission by employing the short form-36, checklist for individual strength, cognitive failure questionnaire and hospital anxiety and depression scale.

Results

27 (79%) of the 34 H-IC+ patients approached, and 93 (85%) of the 109 H-IC− patients approached replied. Data were adjusted for relevant covariates and matched with those of 149 patients in the general ICU. Apart from the lower role-physical functioning score for H-IC+ (P = 0.04) no other differences were found between H-IC+ and H-IC−. Groups H-IC+ and nH-IC+ evaluated their HRQoL on SF-36 similarly, except for the lower aggregated physical component summary (PCS) for H-IC+ (P<0.0001). After adjusting for PCS, no significant differences in CIS, CFQ and HADS were observed between the groups.

Conclusions

Eighteen months after admission, patients treated for haematological malignancies reported similar HRQoL, whether or not they had received intensive care treatment, but reported a lower PCS than those of patients in the general ICU. Hence, there is no reason to assume that admission to the ICU has a negative impact on long-term HRQoL, so this should not affect the decision whether or not to transfer patients with haematological malignancies to the ICU.

Indications and safety of proton pump inhibitor drug use in patients with cancer

INTRODUCTION

Although the exact prevalence of proton pump inhibitor (PPI) use in cancer patients is not known, it is generally perceived to be widespread. PPIs are generally well tolerated and carry an excellent safety profile. However, increasing and longer term PPI use has raised concerns about the risk of pneumonia, bone fractures and enteric infections, and a possible interaction with clopidogrel that could increase the risk of cardiovascular events.

AREAS COVERED

We conducted a PubMed search of English language articles addressing the safety and adverse events associated with PPI use with particular emphasis in cancer patients.

EXPERT OPINION

PPIs, frequently used in cancer patients, are generally well tolerated and carry an excellent safety profile. PPI-induced acid suppression may increase the risk of Clostridium difficile or other enteric infections, nutritional deficiencies and community acquired pneumonia, all particularly important in cancer patients. The indications for PPI use in cancer patients should be carefully reviewed prior to use.

Qualidade de vida de doentes esofagectomizados: adenocarcinoma versus carcinoma epidermoide

OBJETIVO: Avaliar e comparar a qualidade de vida de pacientes esofagectomizados para tratamento de adenocarcinoma da junção esofagogástrica e de carcinoma epidermoide. MÉTODOS: estudo transversal no pós-operatório de doentes esofagectomizados por adenocarcinoma da junção esofagogástrica (Adenoca) e carcinoma epidermóide (CEC), empregando o questionário SF-36 aplicado em 24 pacientes (10 por Adenoca e 14 por CEC), a partir do 5º mês de pós-operatório, incluindo os sintomas clínicos e a variação de peso. RESULTADOS: A avaliação da QV mostrou melhor resultado de capacidade funcional (p=0,018) para o grupo Adenoca. Houve correlação entre os domínios "saúde mental" e "limitação por aspectos emocionais" (p=0,003) e entre "dor" e "limitação por aspectos físicos" (p=0,003) nos dois tipos histológicos. A perda de peso foi maior nos esofagectomizados por Adenoca (45,9Kg), sem diferença significativa entre o IMC atual (p>0,66). A disfagia foi relatada por 83,3% dos pacientes, a anorexia por 58,3%, a dificuldade de mastigação por 42%, a náuseas e os vômitos por 41,7% e a diarréia por 29,2%, sem correlação com a QV relatada (p>0,05). CONCLUSÃO: O escore mais alto para capacidade funcional indica que o paciente com Adenoca foi capaz de realizar todo tipo de atividade física, incluindo as mais vigorosas em um nível maior que o paciente com CEC. Alguns sintomas persistiram no pós-operatório, porém não interferiram na qualidade de vida dos pacientes.

Long-term outcomes and quality of life in critically ill patients with hematological or solid malignancies: a single center study

PURPOSE

Data concerning long-term outcomes and quality of life (QOL) in critically ill cancer patients are scarce. The aims of this study were to assess long-term outcomes and QOL in critically ill patients with hematological (HM) or solid malignancies (SM) 3 months and 1 year after intensive care unit (ICU) discharge, to compare these with QOL before ICU admission, and to identify prognostic indicators of long-term QOL.

METHODS

During a 1 year prospective observational cohort analysis, consecutive patients with HM or SM admitted to the medical or surgical ICU of a university hospital were screened for inclusion. Cancer data, demographics, co-morbidity, severity of illness, organ failures, and outcomes were collected. The QOL before ICU admission, 3 months, and 1 year after ICU discharge was assessed using standardized questionnaires (EuroQoL-5D, Medical Outcomes Study 36-item Short Form Health Survey). Statistical significance was attained at P < 0.05.

RESULTS

There were 483 patients (85 HM, 398 SM) (64% men) with a median age of 62 years included. Mortality rates of HM compared to SM were, respectively: hospital (34 vs. 13%), 3 months (42 vs. 17%), and 1 year (66 vs. 36%) (P < 0.001). QOL declined at 3 months, but improved at 1 year although it remained under baseline QOL, particularly in HM. Older age (P = 0.007), severe comorbidity (P = 0.035), and HM (P = 0.041) were independently associated with poorer QOL at 1 year.

CONCLUSIONS

Long-term outcomes and QOL were poor, particularly in HM. Long-term expectations should play a larger role during multidisciplinary triage decisions upon referral to the ICU.

Addressing patients' information needs: a first evaluation of a question prompt sheet in the pretreatment consultation for patients with esophageal cancer

This study aims to develop and pilot a question prompt sheet to assist esophageal cancer patients to obtain desired information in the consultation in which potentially curative esophagectomy is discussed. Whether a prompt sheet affected patients' question asking, the number and scope of topics discussed, the length of the consultation, and patients' satisfaction is investigated. Patients (n= 30) were randomized either to receive care as usual (control group) or to receive a prompt sheet (intervention group). All patients completed a baseline questionnaire, their consultations were audio-recorded and content-coded, and they received a structured telephone interview 2 days after the consultation to assess satisfaction. Patients provided with the prompt sheet marked a median of 19 questions. They asked significantly more questions as compared with patients in the control group (median of 12 vs. 8 questions). Questions mainly addressed treatment options and procedures. No differences were found with regard to consultation length and patient satisfaction. Our results suggest that providing patients with a simple, easy-to-implement tool such as a question prompt is appreciated and helps patients to ask more questions during the consultation without increasing the length of the consultation.

Postoperative information needs and communication barriers of esophageal cancer patients

OBJECTIVE

Given the poor prognosis of esophageal cancer and the impact of surgery on health-related quality of life (HRQL), addressing patients' postoperative information needs is important. This study aimed to examine (1) the content and type of patients' information needs and (2) patient perceived facilitators and barriers to patient participation.

METHODS

Interviews were conducted with 20 purposefully selected esophageal cancer patients. Open and structured questions were alternated. The transcribed interviews were analysed inductively and deductively, using MAXqda.

RESULTS

Patients' post-operative information needs concerned HRQL, medical care and prognosis, covering several sub-domains. Different types of needs were identified, e.g., requests for information about cause, course and self-management. Barriers to patient participation mostly reflected beliefs and skills, and could be categorized into agenda and communication barriers. Facilitators of patient participation reflected physician, patient and interaction characteristics, companion support and pre-visit preparation. Many patients saw merit in pre-visit preparation interventions; few endorsed skill-building interventions.

CONCLUSION

This study listed the postoperative information needs of esophageal cancer patients. Moreover, it gained insight into patient-perceived barriers and facilitators of patient participation.

PRACTICE IMPLICATIONS

The findings demonstrate what information physicians should have available and informs interventions to support patients in meeting their information needs.

Health-related quality of life after Ivor Lewis esophagectomy

PURPOSE

Transthoracic Ivor Lewis esophagectomy is a surgical standard therapy for esophageal carcinoma. The aim of this study was to assess health-related quality of life (HRQL) in mid- and long-term survivors.

METHODS

Patients with cancer-free survival of at least 12 months after esophageal resection for cancer were identified from a prospectively maintained database. EORTC questionnaires were sent out to assess health-related general (QLQ-C30) and esophageal cancer-specific (QLQ-OES18) quality of life (QOL). A numeric score was calculated in each conceptual area and compared with reference data.

RESULTS

One hundred forty-seven patients completed the self-rated questionnaires. They were 121 men and 26 women with a mean age of 63.4 (21-83) years; median FU was 39 (12-139) months. Global health status, functional scales, and symptom scores were significantly reduced compared with healthy reference populations. Also, there was no significant impact of tumor histology, neoadjuvant treatment, minimally invasive approach, or duration of follow-up on HRQL. However, more than half of the patients reported a HRQL similar to that of the healthy reference population.

CONCLUSIONS

Despite the major psychosocial and physiological impacts of the disease, more than 50 % of mid- and long-term survivors of the Ivor Lewis procedure for esophageal cancer have a HRQL similar to that of the healthy reference population.

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.

Quality of life after esophagectomy for cancer

Esophageal cancer is an aggressive and physically and emotionally devastating disease. It has one of the poorest survival rates among all malignant tumors, mainly due to late symptom presentation and early metastatic dissemination. Cure is possible through extensive surgery, typically followed by a long recovery period, affecting general well-being, as well as basic aspects of life, such as eating, drinking and socializing. Health-related quality of life (HRQL) is a multidimensional concept assessing symptoms and functions related to a disease or its treatment from the patient's perspective. HRQL is a fundamental part of treatment in surgical oncology, particularly in esophageal cancer. This review assesses the scientific data regarding some HRQL aspects after esophageal cancer surgery, for example, postoperative recovery time, determinants of postoperative HRQL and long-term 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.

Functional disorders and quality of life after esophagectomy and gastric tube reconstruction for cancer

Functional disorders such as delayed gastric emptying, dumping syndrome or duodeno-gastro-esophageal reflux occur in half of the patients who undergo esophagectomy and gastric tube reconstruction for cancer. The potential role for pyloroplasty in the prevention of functional disorders is still debated. Antireflux fundoplication during esophagectomy can apparently reduce the reflux but at the cost of increasing the complexity of the operation; it is not widely used. The treatment of functional disorders arising after esophagectomy and gastroplasty for cancer is based mainly on dietary measures. Proton pump inhibitors have well documented efficiency and should be given routinely to prevent reflux complications. Erythromycin may prevent delayed gastric emptying, but it should be used with caution in patients with cardiovascular disorders. In the event of anastomotic stricture, endoscopic dilatation is usually efficient. Problems related to gastrointestinal functional disorders after esophageal resection and gastric tube reconstruction do not significantly impair long-term quality of life, which is mainly influenced by tumor recurrence.

Patients' experiences of the recovery period 12 months after upper gastrointestinal surgery

The aim of this study was to describe and explore participants' experiences of their recovery from upper gastrointestinal surgery and being recovered or not 12 months following their operations. A hermeneutic approach was used to understand participants' experiences and situations. Fifteen participants were interviewed at 12 months postoperatively. According to participants, the year that had passed was experienced as being "pale and gray." Themes that were identified included feelings of doubtfulness, others' concern, and disappointment; never feeling quite well and having to adapt to new circumstances; feelings of being changed; and feelings of becoming free from illness and regaining strength. Being trapped in suffering meant that participants' lives had lost meaningful values. They felt disappointed because of physical discomforts and thoughts about disease and death. Recovery was felt when their physical discomforts decreased, and they felt free from doubts and "difficult" thoughts about illness and death. The recovery process can be understood as a movement between darkness and light.

Health-related quality of life in long-term survivors after high-dose chemoradiotherapy followed by surgery in esophageal cancer

Curative treatment of esophageal cancer with definitive or preoperative high-dose chemoradiotherapy inflicts a major strain on the patients with potentially severe physical, emotional, and social consequences. The aim of this study was to assess various aspects of quality of life and fatigue in long-term survivors following such a treatment. Patients undergoing a potentially curative treatment between 1996 and 2007, and still alive (n= 41) completed quality of life questionnaires of the European Organization for Research and Treatment of Cancer core questionnaire (QLQ-C30) and esophageal cancer module (QLQ-OES18). Twenty patients were treated by surgery alone, and 21 patients were scheduled for high-dose chemoradiotherapy followed by surgery. Five of those patients did not undergo planned surgery. Preoperative chemoradiotherapy consisted of three courses of chemotherapy, cisplatin 100 mg/m(2) and 5-fluorouracil 5000 mg/m(2) in each course and concomitant radiotherapy of a median dose 66 Gy. Quality of life in esophageal cancer patients receiving high-dose chemoradiotherapy was compared with that for esophageal cancer patients who received only surgery, head and neck cancer patients, laryngectomized patients, and a random sample of the general Norwegian population. Esophageal cancer patients treated by high-dose chemoradiotherapy had significantly worse global quality of life as reflected by almost all functional scales and higher fatigue compared with esophageal cancer patients who received surgery alone, head and neck cancer patients, and the general Norwegian population. There were no significant differences in quality of life between the esophageal cancer patients receiving high-dose chemoradiotherapy and the laryngectomy patients. Further, the esophageal cancer patients receiving high-dose chemoradiotherapy had higher intensity of other symptoms like general pain, insomnia, nausea/vomiting, diarrhea, and constipation compared with the esophageal cancer patients who received surgery alone, head and neck cancer patients, and the general Norwegian population. High-dose chemoradiotherapy with cisplatin and 5-fluorouracil had a considerable negative long-term effect on global quality of life in patients with resectable esophageal cancer. Fatigue was a prominent long-lasting symptom in these patients.

Quality of life after intensive care: a systematic review of the literature

OBJECTIVES

To evaluate quality of life at least 12 months after discharge from the intensive care unit of adult critically ill patients, to evaluate the methodology used to assess long-term quality of life, and to give an overview of factors influencing quality of life.

DATA SOURCES

EMBASE-PubMed, MEDLINE (OVID), SCI/Web of Science, the Cochrane Library, Google Scholar, and personal files.

DATA EXTRACTION

Data extraction was performed independently and cross-checked by two reviewers using a predefined data extraction form. Eligible studies were published between 1999 and 2009 and assessed quality of life ≥12 months after intensive care unit discharge by means of the Medical Outcomes Study 36-Item Short Form Health Survey, the RAND 36-Item Health Survey, EuroQol-5D, and/or the Nottingham Health Profile in adult intensive care unit patients.

DATA SYNTHESIS

Fifty-three articles (10 multicenters) were included, with the majority of studies performed in Europe (68%). The Medical Outcomes Study 36-Item Short Form Health Survey was used in 55%, and the EuroQol-5D, the Nottingham Health Profile, the RAND 36-Item Health Survey, or a combination was used in 21%, 9%, 8%, or 8%, respectively. A response rate of ≥80% was attained in 26 studies (49%). Critically ill patients had a lower quality of life than an age- and gender-matched population, but quality of life tended to improve over years. The worst reductions in quality of life were seen in cases of severe acute respiratory distress syndrome, prolonged mechanical ventilation, severe trauma, and severe sepsis. Study quality criteria, defined as a baseline quality of life assessment, the absence of major exclusion criteria, a description of nonresponders, and a comparison with a reference population were met in only four studies (8%). Results concerning the influence of severity of illness, comorbidity, preadmission quality of life, age, gender, or acquired complications were conflicting.

CONCLUSIONS

Quality of life differed on diagnostic category but, overall, critically ill patients had a lower quality of life than an age- and gender-matched population. A minority of studies met the predefined methodologic quality criteria. Results concerning the influence of the patients' characteristics and illnesses on long-term quality of life were conflicting.

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

OBJECTIVE

Clinical outcomes have been investigated extensively in studies of esophageal cancer treatment. Less is known about long-term health-related quality of life outcomes. The aim of this study was to assess a range of health-related quality of life outcomes in patients with esophageal cancer treated with potentially curative intent at least 1 year earlier.

METHODS

Between January 1995 and December 2007, 163 consecutive patients with cancer of the esophagus underwent a potentially curative treatment. All patients with a minimal follow-up of 1 year and without tumor recurrence were eligible. Questionnaires included the European Organization for Research and Treatment of Cancer core questionnaire (QLQ-C30), the European Organization for Research and Treatment of Cancer esophageal cancer-specific questionnaire (QLQ-OES18), and additional questions concerning survivorship issues.

RESULTS

Thirty-seven patients met the inclusion criteria, of whom 36 completed the questionnaires. Twenty-one patients had received neoadjuvant therapy followed by surgery, 9 patients had undergone surgery only, and 6 patients had chemoradiation only. Median survival was 54 (range, 16-162) months. In general, patients reported better health-related quality of life than a reference sample of patients with esophageal cancer, but somewhat compromised health-related quality of life compared with a reference sample of individuals from the general population. Although some symptoms continued to persist, patients' overall evaluation on their treatment, employment status and finances, body weight and image, and survivorship issues was positive.

CONCLUSIONS

Patients who survive 1 year or more after potentially curative treatment for esophageal cancer can lead satisfactory lives. The results of this study can be used when informing patients with esophageal cancer about the long-term effects of treatment.

Preoperative and early postoperative quality of life predict survival in potentially curable patients with esophageal cancer

BACKGROUND

In patients with esophageal cancer, evidence for prognostic significance of preoperative quality of life (QoL) is limited, while the prognostic significance of postoperative QoL has not been investigated at all.

AIM

To determine whether preoperative and postoperative QoL measurements can predict survival independently from clinical and pathological factors, in patients with potentially curable esophageal adenocarcinoma.

METHODS

A randomized controlled trial was performed from 1994 to 2000 in two academic medical centres, comparing transthoracic and transhiatal esophagectomy. QoL questionnaires were sent before and 3 months after surgery (Medical Outcome Study Short Form-20 and Rotterdam Symptom Checklist). Uni- and multivariate Cox regression analyses were used to examine firstly the prognostic value of preoperative QoL and several clinical factors, and secondly of postoperative QoL, several clinical factors, and pathological staging.

RESULTS

Out of 220 randomized patients, 199 participated in the QoL-study. In the multivariate preoperative model physical symptom scale (p = 0.021), tumor length (p = 0.034), and endosonographic T-stage (p = 0.003) were predictive for overall survival. In the postoperative multivariate analysis, social functioning (p = 0.035), pain (p = 0.026), and activity level (p = 0.037) predicted survival, besides pathological T-stage (p < 0.001) and N-stage (p < 0.001).

CONCLUSION

In the present paper the first large consecutive series of potentially curable esophageal cancer patients is presented in whom prospectively collected QoL data before and after potentially curative surgical resection were used to predict survival. Both preoperative (physical symptoms) and postoperative (social functioning, pain, and activity level) QoL subscales are independent predictors of survival in potentially curable patients with esophageal adenocarcinoma.

The Seattle protocol does not more reliably predict the detection of cancer at the time of esophagectomy than a less intensive surveillance protocol

BACKGROUND & AIMS

The optimal management of high-grade dysplasia in Barrett's esophagus remains controversial. A biopsy protocol consisting of 4 quadrant jumbo biopsies (every 1 cm) with biopsies of mucosal abnormalities (the Seattle protocol) is considered to be the optimal method for detecting early cancers in patients with high-grade dysplasia, although it has never been validated. This study aimed to determine the frequency of unsuspected carcinoma at esophagectomy in Barrett's esophagus patients with high-grade dysplasia who underwent the Seattle protocol and to compare the findings with those of a less rigorous biopsy protocol.

METHODS

Thirty-three patients with high-grade dysplasia underwent esophagectomy. None had obvious mass lesions at preoperative endoscopy. Patients were divided into group 1 (preoperative surveillance biopsies according to Seattle protocol) and group 2 (4 quadrant biopsies every 2 cm). Preoperative and postoperative diagnoses were confirmed by 2 expert gastrointestinal pathologists.

RESULTS

Unsuspected intramucosal cancer was found in 8 of 20 (40%) patients in group 1 versus 4 of 13 (30%) in group 2 (P = .6). Preoperative mucosal nodularity was observed in 4 of 8 (50%) postoperative intramucosal cancers from group 1 versus 3 of 4 (75%) from group 2. Multifocal high-grade dysplasia was seen preoperatively in 7 of 8 (87.5%) postoperative intramucosal cancers in group 1 versus 2 of 4 (50%) in group 2. No patient had submucosal cancer or lymph node metastases at surgery.

CONCLUSIONS

Intense preoperative biopsy sampling by the Seattle protocol does not more reliably predict the detection of cancer at the time of esophagectomy than a less intensive surveillance protocol. This calls into question the concept that extensive sampling with the Seattle protocol consistently detects early cancers arising in Barrett's esophagus patients with high-grade dysplasia.

Cost comparison study of two different follow-up protocols after surgery for oesophageal cancer

BACKGROUND AND AIM

Costs of follow-up strategies in patients after surgery for oesophageal cancer have not been evaluated. We therefore randomised 109 patients to standard outpatient clinic follow-up by a surgeon (n=55) or home visits by a specialist nurse (n=54) and compared costs between these two strategies.

METHOD

Cost comparisons included comprehensive data on hospital costs, diagnostic interventions and extramural care. Detailed information on health care consumption was obtained from a case record form at 6 weeks, and 3, 6, 9 and 12 months after randomisation.

RESULTS

Total medical costs were lower for nurse-led follow-up (euro 2592 versus euro 3798) than standard follow-up, although this difference was not statistically significant (p=0.11). This advantage in the nurse-led follow-up group was mainly due to lower costs for follow-up visits (euro 234 versus euro 503; p<0.001), and a trend towards lower costs for total intramural care (euro 1477 versus euro 2277; p=0.19).

CONCLUSION

Nurse-led follow-up of patients after oesophageal cancer surgery is likely to be cost effective and may even generate cost savings. The results of this study further support a specific role of nurses in the medical care of patients with malignant diseases.

Nurse-led follow-up of patients after oesophageal or gastric cardia cancer surgery: a randomised trial

Between January 2004 and February 2006, 109 patients after intentionally curative surgery for oesophageal or gastric cardia cancer were randomised to standard follow-up of surgeons at the outpatient clinic (standard follow-up; n=55) or by regular home visits of a specialist nurse (nurse-led follow-up; n=54). Longitudinal data on generic (EuroQuol-5D, European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30) and disease-specific quality of life (EORTC QLQ-OES18), patient satisfaction and costs were collected at baseline and at 6 weeks and 4, 7 and 13 months afterwards. We found largely similar quality-of-life scores in the two follow-up groups over time. At 4 and 7 months, slightly more improvement on the EQ-VAS was noted in the nurse-led compared with the standard follow-up group (P=0.13 and 0.12, respectively). Small differences were also found in patient satisfaction between the two groups (P=0.14), with spouses being more satisfied with nurse-led follow-up (P=0.03). No differences were found in most medical outcomes. However, body weight of patients of the standard follow-up group deteriorated slightly (P=0.04), whereas body weight of patients of the nurse-led follow-up group remained stable. Medical costs were lower in the nurse-led follow-up group (€2600 vs €3800), however, due to the large variation between patients, this was not statistically significant (P=0.11). A cost effectiveness acceptability curve showed that the probability of being cost effective for costs per one point gain in general quality-of-life exceeded 90 and 75% after 4 and 13 months of follow-up, respectively. Nurse-led follow-up at home does not adversely affect quality of life or satisfaction of patients compared with standard follow-up by clinicians at the outpatient clinic. This type of care is very likely to be more cost effective than physician-led follow-up.

Anastomotic strictures and delayed gastric emptying after esophagectomy: incidence, risk factors and management

The aim of this study was to report the incidence, risk factors, and management of gastric conduit dysfunction after esophagectomy in 177 patients over a 3-year period in a single center. Patients with anastomotic strictures or delayed gastric emptying (DGE) were identified from a prospective database. Anastomotic strictures occurred in 48 patients (27%). Eighty-three percent of early anastomotic strictures (<1 year) were benign, and all late strictures (>1 year) were malignant. Dilatation was effective in 98% of benign and 64% of malignant strictures. DGE occurred in 21 patients (12%), and was associated with both anastomotic leak (P = 0.001) and anastomotic stricture (P = 0.001). 4/8 patients with late DGE (>3 months postesophagectomy) were tumor-related. Pyloric dilatation was effective in 92% of early and 63% of late DGE. Pyloric stents were inserted in 3 patients with tumor-related DGE. After esophagectomy, early anastomotic strictures (within 1 year) and early delayed gastric emptying (within 3 months) are usually benign and respond to dilatation. However, patients presenting later with tumor-related obstruction are unlikely to respond to anastomotic or pyloric dilatation and should be stented.

An audiovisual information resource to assist in the transition from completion of potentially curative treatment for cancer through to survivorship: a systematic development process

INTRODUCTION

Improvements in cancer screening and treatment are resulting in an increase in the number of cancer patients completing treatment who are apparently cured of their disease. There are few information resources for people at this juncture. An evidence-based DVD was developed for individuals at this stage with information about experiences encountered as a cancer survivor (CS).

METHODS

Focus groups and a literature review were conducted to establish the DVD content. The DVD was developed in conjunction with a multidisciplinary committee and according to a recommended best-practice framework. Interviews with CS and evidence-based commentary by health professionals (HP) made up the DVD. The final phase of development was to evaluate the usefulness and acceptability of the DVD with CS and HP.

RESULTS

A 52-min DVD with nine chapters was developed featuring 13 CS, a medical oncologist and a clinical psychologist. Thirty-two CS and 116 HP evaluated the DVD. Both groups considered the DVD was informative (CS 97%; HP 98%), easy to understand (CS and HP 100%), reassuring (CS 91%; HP 92%), relevant to their circumstances (CS 68%; HP 97%), did not contain too much information (CS 75%; HP 71%) and was not distressing to watch (CS 84%; HP 80%).

DISCUSSION

The DVD was well accepted by both CS and HP. Modifications were made as a result of the evaluations, the most significant of which was re-filming of commentary by the two HP. Future research should evaluate the effectiveness of the DVD in controlled trials with outcomes such as quality of long term health, symptom burden and cancer specific distress.

IMPLICATIONS FOR CANCER SURVIVORS

The DVD is expected to be a useful resource for CS living beyond effective treatment for cancer.

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

BACKGROUND

The aim of the study was to assess health-related quality of life (HRQL) in patients with surgically cured oesophageal cancer.

METHODS

A Swedish nationwide cohort of patients undergoing oesophagectomy for cancer between April 2001 and January 2004 was studied prospectively, and compared with a Swedish age- and sex-adjusted reference population. Validated European Organisation for Research and Treatment of Cancer quality of life questionnaires were used to assess HRQL at 6 months and 3 years after surgery. A mean score difference of 10 or more between groups was considered clinically relevant and tested further for statistical significance.

RESULTS

Of 358 patients, 117 (32.7 per cent) survived for at least 3 years. Of these, 87 patients (74.4 per cent) responded to the questionnaires. Six months after surgery, most aspects of HRQL were substantially worse than in the reference population with no improvement at 3 years. Patients alive at 3 years reported significantly poorer role and social function, and significantly more problems with fatigue, diarrhoea, appetite loss, nausea and vomiting, than in the reference population.

CONCLUSION

HRQL in long-term survivors after oesophagectomy does not improve between 6 months and 3 years after surgery, and is worse than that in a comparable reference population.

Symptom burden in cancer survivorship

INTRODUCTION

The subjective experience of cancer survivorship can be assessed by various patient-reported outcome (PRO) methods, including measures of symptom burden and health-related quality of life (HRQOL). Symptom burden includes the presence and severity of multiple symptoms and the level of distress caused by symptoms that go untreated or unrelieved. The concept of symptom burden is more limited in scope than HRQOL but may provide information that better describes the status of various stages of survivorship. This paper contrasts symptom burden with general HRQOL and addresses the importance of including symptom burden as research tool throughout the trajectory of cancer survivorship.

METHODS

We summarized studies that illustrate both HRQOL and symptoms as outcomes of treatment and of descriptive studies of cancer survivorship. Survivorship was operationally defined as beginning at the completion of primary anticancer treatment.

RESULTS

HRQOL and symptom burden measures both provide meaningful but conceptually different data. Both types of measures are important in portraying aspects of cancer survivorship over time, although symptom burden may provide sufficient information to inform treatment decisions and identify long-term effects of cancer therapies.

CONCLUSIONS

Cancer survivors are at risk for multiple severe and persistent symptoms, and assessing and monitoring the severity and impact of these multiple symptoms is critical to understanding the survivorship experience. The inclusion of multiple symptom measures along with the development of new and better methods of long-term symptom tracking in survivors is a critical step in improving the heath status of survivors.

IMPLICATIONS FOR CANCER SURVIVORS

Late and long-term effects seen in cancer survivors have historically been understudied. Symptom burden is an important area of assessment that can be used to specifically describe the symptoms that distress survivors. More descriptive data in this growing population may help identify biological processes in symptom production and maintenance, and facilitate in the development of better treatment and prevention to enhance cancer survivorship.

Patient preferences for the disclosure of prognosis after esophagectomy for cancer with curative intent

INTRODUCTION

The aim of this study was to determine the preferences for content, style, and format of prognostic information of patients after potentially curative esophagectomy for cancer and to explore predictors of these preferences.

PATIENTS AND METHODS

This multicenter study included a consecutive series of patients who underwent surgical resection for cancer in the past 2 years and who did not have evidence of cancer recurrence. A questionnaire was used to elicit patient preferences for the content, style, and format of prognostic information. Sociodemographic characteristics, clinicopathological factors, and quality of life (EORTC QLQ-30 and OES18) were explored as predictors for certain preferences.

RESULTS

Of the 204 eligible patients, 176 patients (86%) returned the questionnaire. The majority of patients desired prognostic information. Information preferences declined when information became more specific and more negative. Married patients and higher-educated patients were more likely to want all prognostic information. The majority of patients wanted their specialist to start the discussion about prognosis. However, a significant proportion of these patients wanted their specialist to first ask if they want to have prognostic information. The percentage of patients wanted a realistic and individualistic approach was 97%. Words and numbers were preferred over visual presentations.

CONCLUSION

After potentially curative esophagectomy for cancer, the majority of patients want detailed prognostic information and want their specialist to begin the prognostic discussion. Patients prefer their doctor to be realistic; words and numbers are preferred over figures and graphs.

The role of health-related quality of life outcomes in clinical decision making in surgery for esophageal cancer: a systematic review

BACKGROUND

Esophagectomy for cancer offers a chance of cure but is associated with morbidity, at least a temporary reduction in health-related quality of life (HRQL), and a 5-year survival of approximately 30%. This research evaluated how and whether HRQL outcomes contribute to surgical decision making.

METHODS

A systematic review identified randomized trials and longitudinal and cross-sectional studies that assessed HRQL after esophagectomy with multidimensional validated questionnaires. Articles were independently evaluated by two reviewers, and the value of HRQL in clinical decision making was categorized in three ways: (1) the assessment of the quality of HRQL methodology according to predefined criteria; (2) the influence of HRQL outcomes on treatment recommendations and/or informed consent; and (3) the HRQL after esophagectomy for cancer in methodologically robust studies.

RESULTS

Eighteen publications were identified, of which 16 (89%) were categorized as having robust HRQL design. Of these studies, 3 concluded that HRQL influenced treatment recommendations and 11 (including the former 3) informed patient consent. The remaining five papers were well designed, but the authors did not use HRQL to influence treatment recommendations or informed consent. After esophagectomy, patients report major deterioration in most aspects of HRQL with slow recovery.

CONCLUSION

HRQL outcomes are relevant to surgical decision making. Methods to communicate HRQL outcomes to patients are required to inform consent and clinical practice.

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

BACKGROUND

Little is known regarding the long-term, health-related quality of life (HRQL) of survivors of esophagectomy for cancer.

METHODS

Consecutive patients completed the validated European Organization for Research and Treatment of Cancer general quality-of life-questionnaire (QLQ-C30) and the esophageal-specific module (QLQ-OES18) before surgery and regularly thereafter for at least 3 years. Mean scores with 95% confidence intervals were calculated. The Student t test for paired data was used to determine differences between baseline and 3-year HRQL scores in which scores differed by >or=5 points.

RESULTS

Of 90 patients who underwent surgery, 47 patients (52%) survived for >or=3 years. In this group, most aspects of HRQL recovered to preoperative levels by the 3-year assessment, except that scores for physical function, breathlessness, diarrhea, and reflux were significantly worse than at baseline (P < .01). However, patients reported significantly better emotional function 3 years after surgery than before treatment (P = .0008).

CONCLUSIONS

Even after 3 years, patients who underwent esophagectomy suffered persistent problems with physical function and specific symptoms. These findings may be used to inform patients of the long-term consequences of surgery.