|GASTROINTESTINAL CANCER SYMPOSIUM - ORIGINAL ARTICLE
|Year : 2014 | Volume
| Issue : 3 | Page : 346-351
Quality of life after oesophagectomy in patients with carcinoma of oesophagus: A prospective study
VPN Ramakrishnaiah1, NR Dash2, S Pal2, P Sahni2, CT Kanti3
1 Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India
2 Department of G I Surgery, All India Institute of Medical Sciences, New Delhi, India
3 Department of HPB Surgery, Institute of Liver and Biliary Sciences, New Delhi, India
|Date of Web Publication||10-Dec-2014|
Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry
Source of Support: None, Conflict of Interest: None
Background: The present study was done to see if quality of life improves following oesophagectomy for carcinoma of oesophagus. Materials and Methods: This was a prospective study done from June 2007 to July 2009. All patients undergoing oesophagectomy and cervical anastomoses for squamous cell carcinoma and adenocarcinoma of oesophagus were included in the study. Quality of life assessment was done using EORTC QLQ C-30 and its oesophagus specific module (OES-18) before surgery and at 3, 6, 9 and 12 months. Results: There were 55 patients who underwent oesophagectomy for carcinoma of oesophagus. On the EORTC functional scale it was noted that patients undergoing transhiatal oesophagectomy showed significant improvement of emotional function only. Patients undergoing transthoracic oesophagectomy showed a decrease in functional scores in the first three months which improved later but this change was not significant. On the EORTC symptom scale, patients undergoing transhiatal oesophagectomy showed significant improvement of constipation but not in other symptoms. Patients undergoing transthoracic oesophagectomy showed an increase in symptoms for the first three months followed by a decrease which was significant with respect to scores for constipation and pain. On the EORTC oesophagus specific symptom scores, patients in both groups showed significant improvement of dysphagia and eating. Conclusion: Patients with carcinoma of oesophagus undergoing transhiatal oesophagectomy may not show significant improvement in quality of life. However there will be significant improvement in dysphagia and eating. Patients undergoing transthoracic oesophagectomy may show an initial decrease in the quality of life.
Keywords: Esophagectomy, neoplasm of esophagus, quality of life
|How to cite this article:|
Ramakrishnaiah V, Dash N R, Pal S, Sahni P, Kanti C T. Quality of life after oesophagectomy in patients with carcinoma of oesophagus: A prospective study
. Indian J Cancer 2014;51:346-51
|How to cite this URL:|
Ramakrishnaiah V, Dash N R, Pal S, Sahni P, Kanti C T. Quality of life after oesophagectomy in patients with carcinoma of oesophagus: A prospective study
. Indian J Cancer [serial online] 2014 [cited 2020 Jan 22];51:346-51. Available from: http://www.indianjcancer.com/text.asp?2014/51/3/346/146750
| » Introduction|| |
Although surgery offers the best prospect for potential cure of oesophageal cancer, radical treatment may result in increased treatment-related mortality, high treatment-induced morbidity, and reduced quality of life. , Such considerations are important as it is questionable if patients are subjected to treatment merely to offer them a few extra months of life, particularly if this is at the expense of quality of survival.  The areas of life or domains that are important to an individual have the most influence on quality of life (QOL).  In the past many centres treating carcinoma oesophagus concentrated on death rates and morbidity data as key outcome measures, , but a growing body of opinion considers that a measure of broader effects of ill health and treatment on the patient's QOL is necessary. , Although there is no strict definition of elements that contribute to health-related QOL, it is generally accepted that they include physical, social, and psychological aspects. ,
Studies on QOL following oesophagectomy are very few from India. Some of the QOL instruments used following oesophagectomy are SF-36 form,  EORTC QLQ C-30 and the disease specific module QLQ-OE 18. In this study we have used the latter to assess QOL following oesophagectomy for carcinoma of oesophagus.
| » Materials and Methods|| |
This was a prospective study done from June 2007 to July 2009. All patients undergoing oesophagectomy and cervical anastomoses for biopsy proven squamous cell carcinoma and adenocarcinoma of oesophagus, from June 2007 to September 2008 were included in the study. Ethics committee clearance was obtained for the study. Informed consent was obtained from all the patients.
Complete demographic data, clinical data and investigations done were recorded on a structured proforma. All the patients were administered the EORTC QLQ C-30 and oesophagus specific module OES-18 (Hindi or English version). The questionnaires were given to the patients one or two days before surgery. After surgery again they were given the same at three or six or nine or 12 months, for at least three times over one year.
For the convenience of analysis patients were divided into two groups. Group I: Patients undergoing transhiatal oesophagectomy (THE), posterior mediastinal or retrosternal gastric pull up and cervical oesophagogastrostomy. Group II: Patients undergoing transthoracic oesophagectomy (TTE), either by posterolateral or anterolateral thoracotomy, posterior mediastinal or retrosternal gastric pull up and cervical oesophagogastrostomy.
The data of both groups of patients were analysed using SPSS version 15.0, software and P < 0.05 was taken as significant. Statistical analysis was done by using Friedman's test for each of the surgical groups followed by multiple comparisons using Wilcoxon Signed Ranks test. Comparison between groups was done, by using Mann-Whitney U test.
| » Results|| |
There were 37 patients in group I (THE) and 18 patients in group II (TTE). The mean age of patients in group I was 51.5 years and that of group II was 55.8 years. Their distribution in group I and II is shown in [Table 1]. Most of the patients with a growth in the midthoracic part underwent transthoracic oesophagectomy, whereas most patients having growth in the lower third underwent transhiatal oesophagectomy.
Forty-three (78.2%) patients had squamous cell carcinoma and nine (16.4%) patients had adenocarcinoma. One patient had leiomyosarcoma and another sarcomatoid carcinoma, whose initially biopsy was reported as squamous cell carcinoma. The distribution of these patients in both groups is shown in [Table 1]. Twenty seven patients received preoperative radiotherapy. Two patients with adenocarcinoma had received chemotherapy prior to presenting to us. Intraoperatively it was noted that 35 patients undergoing transhiatal oesophagectomy had R0 resection and two had R1 resection. Twelve patients undergoing transthoracic oesophagectomy had a R0 resection, where as three patients had R1 and another three had R2 resection. Patients undergoing transthoracic oesophagectomy had higher mean blood loss i.e., 827.8 (500-1500) ml.
Final histopathology revealed that most of the patients were either in stage II (n = 26) or stage III (n = 27) of the disease. One patient belonged to stage I and one patient had carcinoma in situ with Barrett's oesophagitis. Three patients who underwent transthoracic oesophagectomy died in the immediate postoperative period because of a cardiac problem and sepsis. The remaining patients had an average hospital stay of 13.4 days. Those who underwent transthoracic oesophagectomy stayed for an average period of 17.2 days. Postoperatively 12 patients received adjuvant chemotherapy or chemoradiotherapy.
[Table 2] shows the postoperative complications and follow up data. Ten patients had pneumonia. Five patients had recurrent laryngeal nerve injury. Eight patients had anastomatic leak which was managed conservatively. Two patients had chylothorax who had to be reoperated. Three patients had adhesive obstruction and two needed adhesiolysis. Ten patients were lost to follow up. Twenty-three patients (41.8%) died by the end of one year. Three in the immediate postoperative period, three at three months, eight at six months, four at nine months and five at 12 months. Only 24 (43.6%) patients completed the QOL forms at 12 month.
The mean EORTC QLQ-30 functional scale scores of patients in group I showed improvement in global quality of life, physical function, role function, emotional function, cognitive function and social function at three, six, nine and 12 months. However, only improvement in emotional function was found statistically significant [Table 3]a.
In group II, the global quality, physical function, role function, emotional function, cognitive function and social function decreased over the first 3 months followed by improvement at six, nine and 12 month as shown by higher figures, but this was not statistically significant [Table 3]b.
The mean EORTC QLQ-30 symptoms scale score in group I showed a decrease in the scores of symptoms of fatigue, nausea/vomiting, pain, constipation, diarrhoea and financial strain but only the decrease in constipation score was found to be significant. There was a marginal rise in the score of dyspnoea and insomnia in the first six months but was not statistically significant [Table 4]a.
In group II symptom scores of fatigue, nausea, pain, dyspnoea, insomnia, loss of appetite, constipation, diarrhoea and financial strain showed a rise in the first three months followed by a decrease after three months. The decrease in score was statistically significant for pain and constipation [Table 4]b.
[Table 5]a shows symptom scores of EORTC QLQ oesophagus specific module. There was significant improvement in dysphagia, difficulty in eating and dry mouth. Other symptoms such as altered deglutition, pain, loss of taste showed a decrease in scores indicating improvement but were not statistically significant. There was a rise in scores of GI symptoms (heart burn and bile reflux), cough and difficulty in talking showing the effect of reconstruction, but this was not statistically significant. In group II also there was significant improvement in dysphagia and eating. There was increase in the scores of GI symptoms, cough and difficulty in talking but was not statistically significant. There was decrease in the scores of deglutition, pain, taste and dry mouth but was not significant [Table 5]b.
| » Discussion|| |
Quality of life refers to a patient's self reported perception of living a useful and fulfilling life.  There may be a temporary detrimental impact on quality of life following resection. ,,, Quality of life measures may be used to help select patients for oesophagectomy. Hence patient perspective on quality of life is crucial. We are in the era in which health care outcome will increasingly be evaluated from the patient point of view.  Kirby who founded oesophageal patients association suggested nine elements of a good quality of life after oesophagectomy. 
In this prospective longitudinal study we aimed to assess the quality of life following oesophagectomy in patients with carcinoma of oesophagus using EORTC QLQ-C30 and its oesophagus specific module (OES-18).
In our study, on the EORTC functional scale, those patients undergoing transhiatal oesophagectomy did not show a statistically significant improvement in global quality of life, physical function, role function, cognitive function and social function over one year. However, there was significant improvement in emotional function. This may probably be due to the feeling that malignancy has been removed surgically and is in accordance with other studies. , Those patients undergoing transthoracic oesophagectomy showed deterioration in functional scores for the first three months which reached preoperative levels and improved over the next six months though it was not statistically significant. This might be because of the morbidity associated with thoracotomy and the small number of patients in this group but is in accordance with similar study. 
On the EORTC symptom scale, patients undergoing transhiatal oesophagectomy showed no significant decrease in non specific symptoms like fatigue, nausea, vomiting, pain, dyspnoea, insomnia, loss of appetite, diarrhoea and financial strain over one year. However, there was improvement in constipation which indicates good food intake and bowel movement in these patients. Patients undergoing transthoracic oesophagectomy showed an increase in above mentioned symptom scores in the first three months followed by a fall over the next nine months and the fall was significant with respect to symptoms like pain and constipation. This is probably because of healing of thoracotomy wound and increase food intake which is similar to other studies. ,,
On the EORTC oesophagus specific module, patients undergoing transhiatal oesophagectomy showed significant improvement in dysphagia, eating and dry mouth from the third month onwards. There was improvement of deglutition, pain and taste though this was not statistically significant. There was added problem of increase in GI symptoms such as heart burn and bile reflux though statistically it was not significant. This is due to the gastric pull up. Patients who underwent transthoracic oesophagectomy also showed significant improvement in dysphagia and eating from the third month onwards. There was improvement in deglutition, pain, taste and dry mouth though this was not significant. There were additional problems related to GI symptoms, cough and difficulty in talking but this was not significant. These features are similar to studies in the literature. ,,,,
The majority of comparative studies evaluating QOL after oesophagectomy have compared long term survivors to preoperative baseline values or to some established population norms. , There is some amount of paucity of data of QOL in short term survivors after oesophagectomy. One of the best study comparing QOL in short term and in long term survivors is from Blazeby and colleagues.  Patients surviving greater than two years after oesophagectomy reported a decrease in most aspects of QOL and an increased number of symptoms at six weeks after oesophagectomy compared with their pre-treatment baseline. All parameters subsequently improved and reached preoperative levels by nine months. Patients surviving less than two years also suffered decrements in quality of life, early after oesophagectomy. However, almost all of these did not recover to preoperative levels. Interestingly dysphagia scores were similar between these two groups. Patients undergoing palliative treatment were also found to have similar QOL scores as patients who die within two years of surgery. According to this study, oesophagectomy had a negative impact on quality of life in the first two years following surgery but this is transient in those surviving greater than two years. Interestingly dysphagia seems to have only a minor impact on QOL, as has been suggested by other studies. ,,
Some of the limitations of the current study are in finding out the effect of neoadjuvant treatment, residual tumour status, quantity of blood loss, effect of adjuvant treatment, postoperative complication and recurrence on the quality of life assessment. The above mentioned factors may adversely affect the quality of life. To find out the effect of these, larger randomised study of homogenous group of patients, with a long follow up is needed. Some of the studies done on long term survivors of oesophagectomy for carcinoma oesophagus have shown that age, gender, location of lesion, histology, type of operation and use of adjuvant treatment did not affect QOL though there could be transient fall in QOL. ,,
The presence of complications such as postoperative leak or stricture or prolonged hospital stay has been shown to affect the quality of life in some studies. , In the current study eight (14.5%) patients had anastomatic leak and patient who underwent transthoracic oesophagectomy had a prolonged mean hospital stay 17.2 ± 10.0 days. This was not compared because of small number of patients in such subsets.
Given the poor survival after resection for oesophageal cancer, short term quality of life after oesophagectomy is perhaps more important than long term. Few studies have looked at determinants of quality of life in the short term after oesophagectomy. Zieren and co-workers  have found that the most significant factor impacting quality of life was tumour recurrence and this resulted in greater emotional disturbance. Another study has identified neoadjuvant therapy as having negative impact.  on HRQOL, though long term studies show no impact of neoadjuvant therapy on quality of life.  In the current study 20 (36.4%) patients died, during follow up of 12 months, majority of them due to tumour recurrence and complication of recurrence. Some of them died due to stricture related complication such as aspiration. Also it has to be noted that 52.7% of patients received neoadjuvant treatment which might have had negative impact on QOL in the early period of follow up. We also compared the QOL of those patients who died in both groups with those who survived. It was noted that the functional scores were significantly better in those who survived than those who died except social function scores. Scores of symptoms such as fatigue, pain, dyspnoea, insomnia, loss of appetite and constipation were significantly lower in those survived. Those who survived had marked improvement of dysphagia, eating and did not have hoarseness.
| » Conclusion|| |
During the first year follow up, patients with carcinoma of oesophagus undergoing transhiatal oesophagectomy may not show significant improvement in quality of life except emotional function. There may not be significant improvement of nonspecific symptoms except constipation. However there will be significant improvement in dysphagia and eating. Similarly patients undergoing transthoracic oesophagectomy may show an initial decrease in the quality of life and increase in nonspecific symptoms but will have significant improvement in dysphagia and eating. Those patients who undergo a curative oesophagectomy and survive show a significant improvement of quality of life and other symptoms.
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[Table 1], [Table 2], [Table 3], [Table 4], [Table 5]
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