Quality of Life After an Esophagectomy

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Introduction

Esophageal cancer is a challenging clinical problem. Its incidence is rising largely from the increasing diagnosis of adenocarcinoma in the setting of intestinal metaplasia.1, 2 Longevity remains disappointingly low, with 5-year overall survival uniformly around 30% among all patients undergoing a potentially curative resection.3 Esophagectomy, generally performed in the setting of multimodality therapy, offers the best chance of a cure.4 In the past 2 decades, better multimodality therapies including surgical technique refinements have reduced perioperative mortality. Most specialized, high-volume centers now claim 30-day operative mortality rates of less than 5%.5, 6, 7 However, the operation continues to cause severe physiologic stress, with morbidity rates approaching 50%.8, 9 Predictably, this seriously impairs the patient’s physical, social, and emotional functioning.

It has long been argued that common outcome measures of cancer therapy (like survival) do not describe the effectiveness of the intervention adequately.10, 11 This is especially true for aggressive neoplasms with low cure rates like esophageal cancer. The limited survival, coupled with high associated morbidity of therapeutic interventions, makes study of residual QOL of paramount importance to patients and their treating surgeons.12 A more complete understanding of the postoperative health-related quality of life (HR-QOL) may enable the treating surgeon to perform more informed patient selection and better tailor the delivery of intraoperative and perioperative care.

The common use of surveillance endoscopies in the setting of Barrett esophagus has yielded many early carcinomas for which rapidly evolving endoscopic therapeutic modalities have challenged traditional treatments.13, 14 Esophagectomy is no longer the standard approach for high-grade dysplasia, and data are emerging that early invasive cancers may also be managed by endoscopic therapies without compromising survival.15 Given accurate assignment of early stage status, traditional outcome measures such as overall and disease-free survival will likely be too similar to compare new technologies. Less conventional parameters, like cost-effectiveness and HR-QOL, are increasingly important considerations in the formulation of treatment guidelines and shaping overall health policy.

Section snippets

Tools for the evaluation of HR-QOL

Patients’ perspectives of their general well being have had recognized value for a while.16, 17 What has hindered objective assessments of patients’ personal experiences is the lack of valid methods that can be applied easily.18

Until recently, assessments performed to define HR-QOL were done with rudimentary, internal institution questionnaires targeted at evaluating clinically observed sequelae after esophagectomy. Inclusion and exclusion were at the discretion of the investigator designing

Short Term—up to 1 Year Postoperatively

Blazeby and colleagues35 studied the short-term QOL in patients undergoing potentially curative esophagectomy (Table 2). Patients filled out the EORTC QLQ C30 and OES24 questionnaires before treatment, 6 weeks after surgery, every 3 months in the first year, every 6 months in the second year and then annually thereafter. They found a decline in almost all HR-QOL scores after surgery. Interestingly, in the subgroup of patients who survived at least 2 years, the scores improved to preoperative

Neoadjuvant Chemoradiotherapy

Blazeby and colleagues59 studied the impact of neoadjuvant chemoradiotherapy (CRT) on HR-QOL (Table 4). They also compared HR-QOL between patients receiving CRT followed by surgery with those treated by surgery alone. Almost all HR-QOL scores deteriorated during neoadjuvant therapy, but with rapid improvement to baseline before surgery. Global HR-QOL declined significantly at 6 weeks postoperatively, but most aspects recovered to preoperative baseline levels by 6 months regardless of whether

Transthoracic Versus Transhiatal Esophagectomy

In a randomized control trial of transthoracic versus transhiatal esophagectomy, de Boer and colleagues48 examined HR-QOL outcomes using the MOS SF-20 and the Rotterdam Symptom Checklist (Table 5). The surveys were conducted at regular intervals beginning preoperatively and up to 3 years after surgery for a total of 10 evaluations. Global QOL scores showed a small initial decline in both surgical approaches. Thereafter there was continuous improvement approaching to baseline for most aspects by

Summary

Esophagectomy performed in the setting of trimodality therapy remains the best option for potentially curative treatment of esophageal cancer. Despite improvements in operative mortality, it remains a fairly morbid procedure. Reflux, dumping, and dysphagia are the most commonly reported symptoms. However, the impact extends beyond a mere nuisance and can negatively influence the patients’ overall physical, psychological. and social wellbeing. Therefore, overall HR-QOL has recently emerged as a

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