Five-year survival following oesophageal cancer resection: Psychosocial functioning and quality of life

Disability, psychological distress and quality of life in relation to cancer diagnosis and cancer type: population-based Australian study of 22,505 cancer survivors and 244,000 people without cancer

BACKGROUND

Improved survival means that cancer is increasingly becoming a chronic disease. Understanding and improving functional outcomes are critical to optimising survivorship. We quantified physical and mental health-related outcomes in people with versus without cancer, according to cancer type.

METHODS

Questionnaire data from an Australian population-based cohort study (45 and Up Study (n = 267,153)) were linked to cancer registration data to ascertain cancer diagnoses up to enrolment. Modified Poisson regression estimated age- and sex-adjusted prevalence ratios (PRs) for adverse person-centred outcomes-severe physical functional limitations (disability), moderate/high psychological distress and fair/poor quality of life (QoL)-in participants with versus without cancer, for 13 cancer types.

RESULTS

Compared to participants without cancer (n = 244,000), cancer survivors (n = 22,505) had greater disability (20.6% versus 12.6%, respectively, PR = 1.28, 95%CI = (1.25-1.32)), psychological (22.2% versus 23.5%, 1.05 (1.02-1.08)) and poor/fair QoL (15.2% versus 10.2%; 1.28 (1.24-1.32)). The outcomes varied by cancer type, being worse for multiple myeloma (PRs versus participants without cancer for disability 3.10, 2.56-3.77; distress 1.53, 1.20-1.96; poor/fair QoL 2.40, 1.87-3.07), lung cancer (disability 2.81, 2.50-3.15; distress 1.67, 1.46-1.92; poor/fair QoL 2.53, 2.21-2.91) and non-Hodgkin's lymphoma (disability 1.56, 1.37-1.78; distress 1.20, 1.05-1.36; poor/fair QoL 1.66, 1.44-1.92) and closer to those in people without cancer for breast cancer (disability 1.23, 1.16-1.32; distress 0.95, 0.90-1.01; poor/fair QoL 1.15, 1.05-1.25), prostate cancer (disability 1.11, 1.04-1.19; distress 1.09, 1.02-1.15; poor/fair QoL 1.15, 1.08-1.23) and melanoma (disability 1.02, 0.94-1.10; distress 0.96, 0.89-1.03; poor/fair QoL 0.92, 0.83-1.01). Outcomes were worse with recent diagnosis and treatment and advanced stage. Physical disability in cancer survivors was greater in all population subgroups examined and was a major contributor to adverse distress and QoL outcomes.

CONCLUSIONS

Physical disability, distress and reduced QoL are common after cancer and vary according to cancer type suggesting priority areas for research, and care and support.

Quality of life and fear of cancer recurrence after endoscopic treatment for early Barrett's neoplasia: a prospective study

Endoscopic therapy is the treatment of choice for high grade intraepithelial neoplasia (HGIN) or early cancer (≤T1sm1) in Barrett's esophagus (BE). We prospectively evaluated the effect of endoscopic treatment on quality of life (QOL) and fear of cancer (recurrence) and compared this with the effect of Barrett's surveillance or surgery. Patients treated endoscopically for early Barrett's neoplasia (n = 42, HGIN - T1sm1N0M0) were compared with three groups: patients with non-dysplastic BE undergoing surveillance (n = 44); patients treated surgically for early BE neoplasia (HGIN - T2N0M0, n = 21); patients treated surgically for advanced BE cancer (T1N1M0 - T3N1M0, n = 19). QOL (SF-36; EORTC-QLQ-C30; EORTC-QLQ-OES18) and fear of cancer recurrence (Worry of Cancer Scale [WOCS] and the Hospital Anxiety and Depression Scale [HADS]) were measured at baseline, 2 and 6 months after treatment. The endoscopic treatment group reported significantly better QOL in both physical and mental scales of SF-36 and EORTC-QLQ-C30 and less esophageal cancer related symptoms compared to both surgical groups. The endoscopic treatment group reported significant more worry for cancer recurrence (WOCS) compared to the early surgical group. Their scores on the WOCS were comparable with the scores of the advanced surgical group. Endoscopic treatment of early esophageal cancer has less negative impact on QOL and esophageal cancer symptoms than surgery. However, endoscopically treated patients worry as much about cancer recurrence as patients treated surgically for advanced cancer.

Toward improved survivorship: supportive care needs of esophageal cancer patients, a literature review

The growing prevalence of esophageal cancer survivors represent a population typified by an extensive treatment regime, significant postsurgical long-term effects, and a dismal prognosis. Despite this, little is known of the supportive care needs of this patient group and the extent to which these are being met in practice. This review provides a synthesis of the research evidence to date; emphasizing opportunities for clinical application and setting a future agenda with research priorities. A literature search was performed using Medline/Embase, PsycINFO, and Web of Science. Search headings used included; [esophagus] or [esopohageal] or [upper gastrointestinal] or [upper GI] AND [cancer] or [carcinoma] or [squamous cell] AND [supportive care] or [survivorship] or [psychological] or [emotional] or [information] or [social] or [communication] or [spiritual] or [health-related-quality-of-life] or [HRQL] or [qualitative] or [patient narrative] or [clinical nurse specialist] or [CNS]. Related articles in English were reviewed, with additional articles harvested from reference sections. Esophageal cancer survivors report significant late-term effects posttreatment, encompassing sustained impairment in most areas of health-related quality of life. With a necessitated change in eating behavior, survivors find it particularly challenging to adjust to a new social identity and as a cancer population report high levels of psychological morbidity. Although the determinants of psychological morbidity are largely unknown, illness representations may be a key contributor. Several multidisciplinary supportive care interventions have been developed with promising results. The research summarized in this paper provides valuable insight into the psychosocial well-being of the esophageal cancer survivor. However, knowledge gaps remain, alongside a dearth of applied examples in meeting supportive care need.

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

Background

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

Methods

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

Results

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

Conclusions

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

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.

Psychosocial implications of living 5 years or more following a cancer diagnosis: a systematic review of the research evidence

Mortality associated with cancer remains high, but more people are surviving cancer. Some people experience long-term problems associated with cancer and its treatment, and there is a need to know how to support them. This systematic literature review explores primary research for psychosocial implications of long-term survival (>or=5 years) following a cancer diagnosis and interventions designed to address psychosocial problems in the long term. A systematic search of BIDS, BNI, Cancer.gov, CINAHL, Medline, PsychINFO and Web of Science was conducted to identify research publications from 1960 to 2006. Papers were selected on the basis of pre-defined criteria and rated by three independent coders. Forty-three studies met the eligibility criteria. These indicated that most people experience few problems five or more years after their diagnosis of cancer. However, 20-30% of survivors consistently reported problems associated with cancer and its treatment including physical problems, poorer quality of life, psychological distress, sexual problems, problems with social relationships and financial concerns. Not all cancer types are represented in this review. Only two intervention studies met the eligibility criteria. Research is needed to establish appropriate interventions to support those experiencing problems in the long term to enhance well-being.

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.

Generic health-related quality of life amongst patients employing different voice restoration methods following total laryngectomy

Three methods of voice restoration--tracheosophageal speech (TEP), oesophageal speech, electrolarynx--are available following total laryngectomy. TEP produces better voice quality compared with other methods and is assumed to result in better quality of life. Little evidence exists to support the relationship between voice quality and quality of life, however. Advertising this study through several leading laryngectomy charities resulted in the completion of 226 questionnaires (TEP = 147; oesophageal speech = 42; electrolarynx = 37) comprising the Short Form 36 (SF-36) quality of life measure and questions examining perceived voice intelligibility. Additionally, 89 questionnaires comprising only the SF-36 were completed by participants who reported having no serious medical problems, to form a healthy control group. Results indicate that improved voice quality does not result in widespread benefits to quality of life. On only a few dimensions were there differences between voice restoration method: electrolarynx and TEP better than oesophageal speech with respect to pain, TEP better than oesophageal speech with respect to role limitation: physical problems. Additionally whilst widespread differences between voice restoration methods did not occur, all three groups had a worse quality of life compared with the healthy control group. Implications of the results for the selection of voice restoration method to maximize quality of life are discussed.

Quality of life in patients with oesophageal and gastric cancer: an overview

An accurate assessment of health-related quality of life (QoL) in patients with oesophageal or gastric cancer (OGC) is essential to inform clinical decisions by providing insights into patients' experiences of the impact of the disease and its treatments on physical, social and emotional health. Robust QoL questionnaires have been developed and validated in the past decade to measure the QoL of OGC patients. Baseline QoL variables are also prognostic for survival in patients with oesophageal cancer or metastatic gastric cancer. This article reviews the impact of surgery and reconstructive techniques, as well as of adjuvant and palliative treatments on the QoL of patients with OGC.

Multi-dimensional quality of life among long-term (5+ years) adult cancer survivors

Survival from cancer has improved over the past decade resulting in more long-term survivors. The literature on multi-dimensional quality of life (QOL) among long-term (5+ years) adult survivors is reviewed for each of seven cancer sites (i.e. breast, ovarian, cervical, prostate, colorectal, head and neck, and Hodgkin's disease survivors). Overall, long-term survivors experience good to excellent QOL. Physical domain QOL was the most frequently measured while spiritual domain QOL was the least frequently measured. QOL varies according to treatment received and by age for all groups with older persons (excepting head and neck and Hodgkin's disease survivors) reporting better QOL. QOL improves with time for breast cancer survivors and tends to decrease over time for prostate cancer survivors. Issues regarding sexual functioning affected the social domain-especially for breast and prostate cancer survivors. Social support improves psychological domain QOL for breast, cervical, and colorectal survivors. Review of findings may assist researchers and clinicians wishing to enhance the QOL of the long-term survivor population by identifying the most pressing and widely experienced concerns and by providing directions for future research.

Oesophageal cancer: Experiences of patients and their partners

Oesophageal cancer (OC) is a debilitating disease with significant social, psychological and physical impacts on health and lifestyle (Mills and Sullivan, 2000). The research presented in this paper uses a survey method, and reveals that patients require honest communication and more help with everyday living from nurses to facilitate recovery. Each patient is unique but commonalities can be established that improve experience and outcome. Three themes emerged from the data: food, activity and positivity. To meet long-term needs, the Oesophageal Patients Association is fundamental for patients and carers in order adapt to this major life-changing event.