Quality of Life After an Esophagectomy
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.
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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
References (82)
- et al.
Small adenocarcinomas of the esophagogastric junction: association with intestinal metaplasia and dysplasia
Am J Gastroenterol
(2002) - et al.
Increasing incidence of adenocarcinoma of the esophagus and esophagogastric junction
Gastroenterology
(1993) - et al.
Survival after surgery for oesophageal cancer: a population-based study
Lancet Oncol
(2005) - et al.
Outcomes after esophagectomy: a ten-year prospective cohort
Ann Thorac Surg
(2003) - et al.
Outcome studies in surgical research
Surgery
(1997) - et al.
Curative endoscopic resection of early esophageal adenocarcinomas (Barrett’s cancer)
Gastrointest Endosc
(2007) - et al.
A 12-country field study of the EORTC QLQ-C30 (version 3.0) and the head and neck cancer-specific module (EORTC QLQ-H&N35) in head and neck patients. EORTC Quality of Life Group
Eur J Cancer
(2000) - et al.
Validation of the EORTC QLQ-C30 quality of life questionnaire through combined qualitative and quantitative assessment of patient-observer agreement
J Clin Epidemiol
(1997) - et al.
Clinical and psychometric validation of an EORTC questionnaire module, the EORTC QLQ-OES18, to assess quality of life in patients with oesophageal cancer
Eur J Cancer
(2003) - et al.
Clinical and psychometric validation of a questionnaire module, the EORTC QLQ-OG25, to assess health-related quality of life in patients with cancer of the oesophagus, the oesophago-gastric junction and the stomach
Eur J Cancer
(2007)
Six-month postoperative quality of life predicts long-term survival after oesophageal cancer surgery
Eur J Cancer
Long-term outcome of esophagectomy for high-grade dysplasia or cancer found during surveillance for Barrett’s esophagus
J Gastrointest Surg
Health-related quality of life in long-term esophageal cancer survivors after potentially curative treatment
J Thorac Cardiovasc Surg
Quality of life during neoadjuvant treatment and after surgery for resectable esophageal carcinoma
Int J Radiat Oncol Biol Phys
Health-related quality of life in esophageal cancer: effect of neoadjuvant chemoradiotherapy followed by surgical intervention
J Thorac Cardiovasc Surg
Prospective comparison of surgery alone and chemoradiotherapy with selective surgery in resectable squamous cell carcinoma of the esophagus
Int J Radiat Oncol Biol Phys
A comparison of multimodal therapy and surgery for esophageal adenocarcinoma
N Engl J Med
Minimally invasive esophagectomy: outcomes in 222 patients
Ann Surg
Two thousand transhiatal esophagectomies: changing trends, lessons learned
Ann Surg
Hospital volume and hospital mortality for esophagectomy
Cancer
Chemotherapy followed by surgery compared with surgery alone for localized esophageal cancer
N Engl J Med
Quality of life as an outcome measure in surgical oncology
Br J Surg
The role of health-related quality of life outcomes in clinical decision making in surgery for esophageal cancer: a systematic review
Ann Surg Oncol
Impact of endoscopic biopsy surveillance of Barrett’s oesophagus on pathological stage and clinical outcome of Barrett's carcinoma
Gut
Local endoscopic therapy for intraepithelial high-grade neoplasia and early adenocarcinoma in Barrett's oesophagus: acute-phase and intermediate results of a new treatment approach
Eur J Gastroenterol Hepatol
The problem of quality of life in medicine
JAMA
Quality of life in cancer patients—an hypothesis
J Med Ethics
Quality of life measurement: bibliographic study of patient assessed health outcome measures
BMJ
Evaluating the quality of life of cancer patients: assessments by patients, significant others, physicians and nurses
Br J Cancer
The Medical Outcomes Study. An application of methods for monitoring the results of medical care
JAMA
The MOS 36-item short-form health survey (SF-36). I. Conceptual framework and item selection
Med Care
The MOS 36-Item Short-Form Health Survey (SF-36): II. Psychometric and clinical tests of validity in measuring physical and mental health constructs
Med Care
The MOS 36-item Short-Form Health Survey (SF-36): III. Tests of data quality, scaling assumptions, and reliability across diverse patient groups
Med Care
The Functional Assessment of Cancer Therapy scale: development and validation of the general measure
J Clin Oncol
Cross-cultural validation of an international questionnaire, the general measure of the Functional Assessment of Cancer Therapy scale (FACT-G), for Japanese
Qual Life Res
The Functional Assessment of Cancer Therapy (FACT) scale. Development of a brain subscale and revalidation of the general version (FACT-G) in patients with primary brain tumors
Cancer
Validation of the functional assessment of cancer therapy esophageal cancer subscale
Cancer
The European Organization for Research and Treatment of Cancer QLQ-C30: a quality-of-life instrument for use in international clinical trials in oncology
J Natl Cancer Inst
Psychometric properties and responsiveness of the EORTC Quality of Life Questionnaire (QLQ-C30) in patients with breast, ovarian and lung cancer
Qual Life Res
Reliability and validity of a new scale to assess postoperative dysfunction after resection of upper gastrointestinal carcinoma
Surg Today
A prospective longitudinal study examining the quality of life of patients with esophageal carcinoma
Cancer
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Long-term survival after minimally invasive resection versus open pancreaticoduodenectomy for periampullary cancers: a systematic review, meta-analysis and meta-regression
2021, HPBCitation Excerpt :During the past 20 years, significant improvements in peri-operative care combined with improved patient selection have made small but appreciable advances in prolonged survival after pancreaticoduodenectomy (PD).1–4
A systematic review and network meta-analysis of different surgical approaches for pancreaticoduodenectomy
2020, HPBCitation Excerpt :During the last 20 years, significant improvements in peri-operative care combined with improved patient selection have made small but appreciable advances in prolonged survival after pancreaticoduodenectomy (PD).1–4
Alimentary satisfaction, gastrointestinal symptoms, and quality of life 10 or more years after esophagectomy with gastric pull-up
2014, Journal of Thoracic and Cardiovascular SurgeryOutcomes of minimally invasive esophagectomy in esophageal cancer after neoadjuvant chemoradiotherapy
2014, Annals of Thoracic SurgeryLong-term quality of life and alimentary satisfaction after esophagectomy with colon interposition
2014, Annals of Thoracic SurgeryCitation Excerpt :A systematic review of quality of life after esophagectomy showed that pooled scores for physical function, vitality, and general health were lower than the relevant norms [11]. Most of these studies were done within the first few years after an esophagectomy and in patients with gastric pull-ups [11–16]. One study with 5 years of follow-up reported that quality of life improved over time but found that most patients continued to have more digestive problems than the background normal population [14].
Quality of Life in Patients with Esophageal Cancer
2013, Thoracic Surgery ClinicsCitation Excerpt :A disease-specific module is added for esophageal cancer, which consists of 17 items addressing areas such as eating, swallowing, enjoyment of food, voice, dry mouth, appetite, cough, choking, and pain, each evaluated using a 5-point Likert scale to generate a summary score of esophageal-specific concerns.6 In addition to these QOL instruments, several other instruments have been used to evaluate HRQOL in esophageal cancer, including the Rotterdam Symptom Checklist, Spitzer Quality of Life Index, Profile of Mood States, Gastrointestinal Quality of Life Index, and the University of Washington Quality of Life Scale.7 A systematic review of HRQOL assessed using the EORTC QLQ-30 or MOS SF-36 after esophagectomy found 21 studies, 5 of which used the MOS SF-36 and 16 used the EORTC QLQ-30; 14 of 16 also used the OES-18.